Saturday, February 28, 2009

Need your prayers again...

I have to apologize once again for not providing an update sooner - my brain has been in recovery and hibernation mode I think.  I also didn't want to put away the suitcase, go to the grocery store or unpack the last couple bags after our stay - I know that sounds so silly, but my mind is in the habit of going there.  I procrastinated on those last three items until yesterday (and strangely enough, as I walked through the grocery story I thought more than once about turning around and walking out without the groceries - now I have a fridge full of food to consider how to keep fresh!).   Maybe God was preparing us...

We took Peyton back to the hospital last night with severe stomach cramps - he was screaming and yelling and nothing we were doing helped.  After 2 hours of that and the agony of watching him helplessly we decided it was off to the hospital again, against his wishes.  He was ready to stop complaining (how - I don't know... he was in too much pain!) just so he wouldn't have to go back.  Anyway, after an X-Ray and examinations, and after being sick to his stomach for all the wee hours this morning the doctors determined he has another partial bowel obstruction.  It is not severe yet and it was a blessing that we went in when we did, before it could become a significant problem that could require surgery.  He has an NG tube in for the purpose of draining his tummy to provide bowel rest so hopefully the obstruction can work itself out.  They are 99% sure it is due to the plasticity of the scar tissue, and that there are some adhesions related to the scar tissue that are causing the problem.  Our prayer is that the obstructions (multiple spots from appearance of X-Ray this a.m.) will work themselves out quickly and without surgery.  

Peyton looks much better this afternoon than he did this morning, so we are hopeful that he is going to recover without surgery, but please uphold him in your prayers.  He was so discouraged last night when he started to go through this again - you would think you were looking at a little adult if you could have seen him.  The reactions to the pain were more reactions of frustration and pleading than that of just the pain last night.  He is still so brave though - he quickly reminded me as he pulled off something related to a bandaid for the all too common bloodwork this morning that he is brave and can take care of it himself so I know his fighting spirit is still there.  I just don't like to see him downtrodden of spirit.  He won't stay down for long I'm sure, but I think we will forever have a piece of an wizened old man in the little boy we are borrowing from God.

No promises on the next update, then I won't feel like I am letting myself down - but I will inevitably feel the call of the keyboard in the near future.  Thank you for continuing to support our family in following our story!

Saturday, February 14, 2009

Loopy! (Understatement...)

Peyton is becoming less of a tangle-hazard bit by bit. The nose tube and the stomach drain tube came out Saturday afternoon, and I have to admit, the experience is one that will make me smile for a long time (I'll apologize to Peyton when he can understand it better!). Peyton was dreading taking both of the above out for days and would have preferred Saturday drop off the map so he wouldn't have to get them out. You would think he would have been happy to be rid of them, but he was more afraid of the pain involved than he was motivated by the result. As suggested in my last post, the first words out of his mouth yesterday morning were, "Do we have to take my tummy tube out today Mommy?" It was difficult to distract him after that, even though I didn't answer one way or the other. I said we would have to talk to the doctor (I didn't realize how this would influence his opinion of the dr. - see below for corresponding story). As Peyton was so concerned about the procedure, the team decided it would be best to give him a dose of a relaxant to make him calm enough. He would get just enough to relax him, but not enough to knock him out.

About 12:00 yesterday afternoon the anesthesiologist came in with a couple of nurses and Peyton started to get suspicious. Fortunately the anesthesiologist worked quickly and it was only a couple of minutes before Peyton was no longer concerned about all the people standing around his bed. There were at least 7 of us in there, most with the purpose of helping in case something went haywire with the anesthetic, but some of us in there to watch Peyton's reaction. It wasn't long after the anesthetic went in when Peyton noticed the cards on his closet door "floating around the earth." Shortly after that his "eyes got dizzy." Then he started to wink one eye at a time and he decided it was magic that everything was dizzy when both eyes were open, but seemed to hold still when he winked. He thought the anesthesiologist was a magician. When we asked him how many eyes Mommy had he said, "4. No wait. Lots of eyes! They are moving too! And there is one on your forehead!" He tried to touch them and kept touching my eyebrows and forehead. He spent a little time reaching for things floating in the sky after that. The nurses liked his reaction at the start the best - first he just growled, followed by an unprovoked giggle, then he kept laughing at nothing. I think it was the most relaxed and silliest they had seen him this whole stay. It was a nice break, but I don't think I have ever seen anything so strange. Once I put aside the typical mommy concerns, I couldn't help but laugh at his reaction. It was a relief that he didn't freak out when they took the two tubes out. He definitely noticed, and reached for both to intervene, but due to his slowed reaction time he got there a couple seconds after the tubes had exited. He almost got the nose tube, but the anesthesiologist was just a hair quicker. They wouldn't have stood a chance if they hadn't slowed him down! It seemed to bother him a little that there was a "hole" in his right nostril after they took it out too - he stuck his finger up there curiously and just left it there for a couple minutes... I'm not even going to try to explain that affect! After a while of random babbling with slowed, but very intentional speech I finally convinced him sleep was a good thing. Jordan and I waited with anticipation to see what he would remember upon waking, and the result was not disappointing. He woke up relaxed and completely unaware of what had happened. Jordan asked him if he noticed anything different to which he responded that he didn't. Seconds later he went to itch his nose and noticed with a gasp that something was missing! He just started laughing with excitement! Then we asked him if his tummy tube had disappeared too and he reached down tentatively. When he realized it was gone too he nearly started floating with glee. He couldn't figure out how it happened! The charge nurse came in at that point and said it must have been "the Tube Fairies." I can hardly wait to hear what the two doctors think of that title...

Peyton was a different child after coming out from under the influence of the tubes - we didn't realize how much they must have hampered his emotional state! He also came off the pain medicine yesterday afternoon and what a difference today. I came over to his bed this morning for the last hour of his sleep as he was tossing and turning a bit in the hopes I could prolong his sleep for a few more precious minutes. After the noise level in the hall hit a fair buzz and the sounds of the day reached his ears he woke up, looked over at me, and just grinned ear to ear. Wow (and I don't think it was caused by my bed head). If you have read any of my previous posts about Peyton, you know he doesn't often wake up smiling! It was amazing! He is doing well today, and if he keeps up at this rate I'm sure we will be out sooner than later. Thank you for all your prayers, they are blessing our family.

Now back to the afore-promised short story... I was trying to distract Peyton from the fact that it was Saturday yesterday morning so we decided to go for a walk. We were looking for a computer that had the "earth game" on it so we set out on our search. We went to the second floor first, but that computer had the wrong games on it. We then went to the third floor, but that computer was behind locked doors due to it being a weekend. I tried at that point to convince him we should go back and find something else to do, but he was determined now, and would have gone by himself had he not been in a wheelchair. Since I was still in distract mode, I agreed to his insistence that we go down to the first floor to try that computer. We made it there and were able to pass almost an hour before he was ready to head back and face his fate ("ready" said with a "Yeah right" tone). We were on our way back up and he said out of the blue, "Dr. W. is a bad doctor right Mommy?" What? I had to wheel through the morning's events at top speed to figure out what might have triggered that comment and looking back I'm pretty sure it was due to the fact that I kept telling him he had to ask Dr. W. if he could eat, drink, or not have his tubes taken out. Everything that mattered to Peyton rested in Dr. W.'s hands! I quickly corrected him gently and then he responded by asking if there were any bad doctors here. He wanted to make sure he understood this well. The emotional twists on a visit like his have interesting impacts. I'm sure I will have more to write about as we go, and I only hope I can provide him the right comfort or the right comment when needed ("right" said loosely). Anyway, I should probably sign off so I can check on him but I just wanted to let everyone know he is doing well, and entertaining us in the process!

Friday, February 13, 2009

Progress is a good thing

I had every intention of writing Monday or Tuesday and here it is Friday already! If I had the energy, I might feel sorry that I didn't get a post up sooner, but as it is I'm not even sure where Tuesday through this afternoon went!

More important than my concept of time is an update on Peyton - he is doing well in a word. Sunday they were able to take him off of oxygen and he could support his own breathing on the pain medication (that was the main concern). Monday they took the epidural out of his back (they said it wasn't doing any good and when they went to take it out they found it had already dislodged from the site - not helpful, but normal occurrence in children). Tuesday they decreased his pain medication and gave him a patient controlled analgesic push button - without a doubt the most helpful addition of the week, if not the funniest. Wednesday they decreased the pain medication again, we got him out of bed for the first time, and we had the first clear indication that his bowels were working again. Thursday they increased his pain medication for times of sleep, and we forced him to walk to the kitchen down the hall. Friday Peyton vetoed the decision to take his nasal tube out so he had a day off (if there is such a thing here!). I know the above doesn't paint a very clear picture of how he was feeling, but it's a start - those were the major accomplishments of the week. Given the extent of the tinkering the surgeons did inside Peyton's little tummy I am impressed he is progressing as quickly as he is.

Saturday and Sunday last week were pretty much a blur, as were much of Monday and Tuesday. We weren't sure whether we were not yet at the corner, stuck on the corner, or around the corner until Wednesday. At that point, even the surgeon breathed a sigh of relief when it appeared Peyton's bowels remembered what to do. Thursday and Friday were days focused on healing and waiting. There do not appear to be any complications at this point thankfully, but Jordan and I are not in a hurry to go anywhere yet. Peyton himself has been slower to indicate any interest in eating this time around and we are fully supportive of that decision! The surgeon wrote an order that Peyton could start, "Blue popsicles and ice chips" on Thursday (one every 6 hours). Peyton was thrilled with the first one, but by the second one yesterday it felt like we were trying to get him to eat vegetables. He initiated an attack on three more popsicles today, but only conquered 1. We are more than willing to let him lead the way this time, as much as we are eager for him to start eating solids again. Fortunately he is getting most of his nutrition through an IV line right now so he is not wasting away, but he has lost alot of his muscle. I have no doubt it will not take long to build again, but it is so strange to grab his thighs to tickle them and to feel them squish in your hand the way they do! Poor skinny little fellow!

I briefly mentioned our affinity for the "pain button" - I should really explain. The first time Peyton had surgery a couple weeks ago we gave him Morphine, after which we decided he and Morphine were not compatible (grumpy describes his mood on it nicely). This time around we decided to go with Fentanyl in hopes it would more positively impact him. It has been much better from that angle, but we were told all opiates can slow the gut down so the anesthetist wanted to drop his dose as quickly as possible to lower that risk. The best way to do that was to provide the option to increase the med dose when we knew he would be more likely to experience discomfort, like when he had to sit up, move or start walking. It also provided a very necessary emotional aspect of healing for Peyton in providing an element of control over his discomfort. To illustrate best, you would have had to watch him the first time we tried to get him out of bed into a nearby chair. We gave it a push a little in advance and again when he sat up and began to move. He pushed it a few times in the process of moving to the chair, but when we moved him back to the bed from the chair he pushed it no less than 29 times! Thank goodness there is a lockout period so he can only get one dose every 6 minutes, but he was pushing for all he was worth! We finally had to nearly wrench the button from his hot little fist or he would have kept pushing! He also quickly learned that lying still was lots more comfortable, so between knowing what the button does and which position is best, it's a good thing he's an active little boy who won't stop for long or he would forget he didn't really think he could move! I was initially worried he would become dependent on it, but he forgot about it today and didn't feel the need to use it once all day (besides, we kind of accidentally hid it and Mommy forgot about it too!). Hopefully we will be able to go to oral pain relief methods soon, if any are needed at all. He is so much tougher than I feel I would be given the same circumstances!

Tomorrow the surgeon is hoping to take the drain out of his stomach and Peyton is less than thrilled with the idea. He doesn't want tomorrow to come and I can almost guarantee what his first thought will be tomorrow morning. Hopefully the surgeon will be by first thing rather than last and it will go smoother than we expect. Peyton tends to fear a situation more than he actually has a problem with the actual situation and I expect this will be the same (don't know where he got that tendency from...). This will be a big step in the healing though, and it will be so nice not to have that cord attached to worry about. (I nearly ripped it out lifting him into his wheelchair yesterday when it got stuck on the foot pedal of the wheelchair! He quickly let me know something was not right and I paused with him in mid-air, and mid-scream until we figured out what had happened!)

I would love to write more but I am realizing the above is not as coherent as it could be and my brain seems to be in sleep mode though my eyes are still open. I will sign off and promise to write more later but better not say when! We love you all and are so thankful as always for your prayers. Please add a few children to your list: Abby, Mikayla, and Oliver - they are dear children with amazing parents and we pray God will bless their families abundantly.

Sunday, February 8, 2009

My son the warrior

Peyton - Tuesday, January 20 (before admission!)
Peyton after admission, but before diagnosis of appendicitis.
Peyton after surgery to remove appendix and abscess.
Peyton well into first recovery, using his NG drainage tube as a lasso.
Peyton on MORPHINE (They are NOT compatible!  terrible mood!)

We chose the name Peyton because we wanted to give him a legacy to live up to, to let him know we believed in him even before he was born.  We deliberated over quite a few names, but it came down to Peyton Nathaniel.  Peyton means, "from the house of the warrior," and Nathaniel means, "blessing from God."  He is living up to his name through this experience.  He is so brave and we are so proud of him!  Beyond that, we are thankful.

I will try to provide a brief update, but if I look back at most of my posts, I tend to be anything but brief.  My apologies!  One day perhaps I will write short posts...

The last time I had time to sit down and write we were waiting for an ultrasound to determine whether or not the three secondary abscesses that had formed due to the ruptured appendix had resolved themselves or whether they would require drainage.  The doctors canceled the ultrasound because they wanted to wait a little longer to see if the antibiotics would clear them up.  They talked about switching him to oral antibiotics and doing a follow up ultrasound later (which means they likely would have discharged us sooner than later).  We were a little nervous about the idea of taking him anywhere before we knew exactly what we were dealing with.  It turns out that we didn't have to deal with that uncertainty, there was a different emotion for us to deal with instead.

Monday he was beetling around the hallways, bugging nurses and trying to stop Mommy's heart by careening down the hall with his speed shuffle leaving Mommy to steer the IV pumps around any obstacles in his path.  After a while I decided to try to slow him down by making him manage the IV pump pole but that plan backfired.  He realized quickly that he now had freedom and could move even faster!  We had the charge nurse in a panic when he got away down the hall before I could catch up and all parties were worried he would slip and hurt something before any of us could get there!  My strong little boy, oh how he makes me smile.

Tuesday he was alright in the morning but he didn't feel well in the afternoon and he was worse by evening.  By late evening he was sick to his stomach every hour to two hours and had severe cramping (with no pain medication to manage it) that continued through Friday.  He couldn't keep anything in his stomach, and even after they put him on a nasal tube (NG) drain to drain his stomach of its own contents (he was no longer eating at this point) he could only go for a couple hours without getting sick.  We took him for an X-ray Wednesday, Thursday, and Friday morning in the hopes of determining if he had a blockage in his bowels as a result of his appendix rupturing.  They couldn't tell on Wednesday, and Thursday's X-ray was actually better.  His blood work was telling a different story on Thursday, but it was better by Friday.  The surgeon decided he didn't want to take any chances so he sent Peyton for a CAT scan on Thursday morning (I quickly got over my reluctance when he explained the consequences of not sending him for one - either get one done or he would do surgery that day to go in himself and see what was happening, and he was serious!).  The CAT scan showed that he had a partial blockage so they wanted to wait a bit to see if it would resolve itself.  Friday Peyton was still sick to his stomach and seemed even more ill so the surgeon got one of his colleagues to review the X-rays and CAT scan with him.  They came by around lunch and said, "We have to go in, and we have to go in soon.  There is now a full blockage and we are worried it will be a major surgery."  The disadvantage of surgery at this point of his recovery was that the chances of them being able to do it laparoscopically were slim and if they had to go in, it could end up being a 4 - 5 hour surgery, requiring a possible blood transfusion and could involve doing a temporary colostomy (where they would bring his bowels to the surface, leave a hole for drainage, let the bowels recover and then repair after they heal).  We didn't know how to respond, but it was agony watching Peyton suffer so much so we were willing to do anything for him at this point!

Friday at 4:45 pm we wheeled him in for surgery and only reluctantly left him behind.  It was an awful feeling walking out of that room, leaving him behind and remembering the other times we had walked out of that room knowing we were leaving someone we loved in the (very capable) hands of someone they didn't know.  We left Drew in that room twice and Peyton in there twice now as well.  No words could adequately describe the strange feeling we felt walking away empty-armed, a double impact.

We waited, knowing that if they didn't bring him back within an hour and a half or so it would mean they were doing a major surgery.  By 8:00 we were still waiting.  By 9:00 they let our nurse know he was in recovery and the surgeon walked in to tell us about the surgery.  I was down in the ICU visiting the little girl we have requested your prayers for when I got a call that the surgeon was there.  I don't think I've ever run faster to get someplace!  Peyton's surgeon said they went in laparoscopically and found adhesions everywhere, which would have likely been the result of the abscess.  One of the other surgeons mentioned during the surgery that that was great and now they wouldn't have to do a major surgery.  Peyton's head surgeon disagreed.  He saw bile and said, "If this is bile, there is a hole somewhere."  God blessed us with this surgeon - someone else might have sewed him back up before finding the real problem!  He decided he would have to open him up more to go through Peyton's bowels in search of any holes and found 3, up by the left rib cage.  They were likely the result of the inflammation of his intestines due to the original rupture, which then led to a kink in the large intestines, which in turn cut off the blood supply and allowed it to start decaying.  He believed the holes were the outcome of the decay that had weakened the intestines in that spot.  Peyton's intestinal contents had been leaking for some time probably, as there was bubbly matter and tiny abscesses all over the cavity.  The anesthetist said it looked like hamburger.  Great.  That belongs in the stomach itself, not the stomach cavity!  

The surgeon was able to repair the three holes and cleaned the area out as well as he could before sewing him back up.  They were also able to use 2 of the 3 previous incisions, although they had to enlarge them a bit, so Peyton only got two new holes out the deal.  The largest one is only about 2 inches wide amazingly.  The surgeon thought the surgery went well and I was relieved that Peyton wasn't going to be coming back with his stomach inside out!  We tried not to contemplate how we would deal with that ahead of time, but I have to admit I found myself asking where the necessary strength would come from.  

I nearly cry now thinking about the moment they wheeled Peyton back into his room Friday night.  He was so brave!  He had to go through going to sleep with strange people wearing strange masks and clothes, surrounded by scary equipment and then waking up with much of the same, with no familiar faces nearby.  I just wanted to cuddle him close and make it all better Friday night, but he was so uncomfortable and so tangled up in cords we couldn't get too close!  He came back with an NG tube in his nose to drain his tummy, a drain from one of his incisions, a catheter, an IV site with four lines in one arm and an IV site with two lines in the other, an oxygen saturation monitor on one of his little fingers, and oxygen prongs in his nose to help him breath after all the medication they had to give him.  You would think a boy with his spunk would fight these bonds tooth and nail, but he hasn't for a minute!  He just moves them with him if he tries to move.  We went to take off the nasal prongs today and he got upset that we were going to remove them.  I think he was afraid it might hurt - I can't imagine any other reason he would not want to be free of one of the many things connecting him to his bed!

The surgeon mentioned Friday night that though he felt the surgery was a success, we were not out of the woods yet.  The first couple of days would be very critical to determine whether it was a success and Peyton would be at risk for a few complications.  1) The sutures might not hold, especially if there is too much pressure on them, so he can have NOTHING going through his bowels and even gas could cause a problem.  2) He could develop more secondary abscesses or infection.  3) The surgeon added a new risk yesterday after we realized Peyton was having difficulty breathing which was quickly followed by more X-rays - he could develop pneumonia as a result of the collapse of his lower left lung lobe.  It was likely impacted by the inflammation of the bowel directly below it.  This last risk necessitated a regular visit by a physiotherapist a couple times a day in hopes that we can open that lobe back up fully and prevent pneumonia.  He seems to be breathing better today, but breathing has been challenging because it hurts to expand his rib cage and lungs.

He has been doing much better today than yesterday, so Mommy and Daddy are doing better as well.  He is still very weak and uncomfortable, and we are not yet sure whether we have turned the corner so please keep him (and us!) in your prayers as Peyton continues to prove he is truly a warrior of the bravest sort.

I will try to post again tomorrow or Tuesday provided no complications arise and time allows.  Thank you for following our journey!

Working on a post as we speak

Check back in an hour!  Sorry for the delay!

Monday, February 2, 2009

No ultrasound results yet

I'm not sure how I would feel in Peyton's shoes today but I don't think I would be very happy with the world! He went to sleep last night after a conversation with the nurse where he found out he had to have blood work (NEEDLES!!!) first thing this morning. As he was drifting to sleep he said something about tomorrow never coming. The surgical resident was in at 7:30 this morning to examine him so he awoke to us poking and prodding him, which began to set the tone. (You also have to know that he inherited his "love" of mornings from one of the two of his parents.) After that, he asked me if it was tomorrow now. I had to be honest so I answered yes, to which he responded appropriately (although his reaction warranted the closing of the door opposite us). He wanted to know when they were coming so once again I was more honest than I probably should have been. I told him they would be coming at 8:00, when the long hand of the clock was on the 12. I've never seen a child his age watch a clock so anxiously! Every minute or two he would glance at it, panic, and say, "Mom! Look! Look at the clock! Oh no!" This was in spite of my sincerest attempts to distract him. We finally resorted to watching TV and he calmed down until the lab cart wheeled up. Again, the door across the hall closed. The lab techs know us by now so they tried to do what they could to make it better, but he was not about to make friends with those that have to poke him. He had worked himself up so much that the first attempt was a failure - he was so worked up that the vein collapsed! After the second poke and a quick chat, he quickly caught onto the fact that if he didn't calm down they would have to do it a third time. Now if only I can get him to breath like that every time they come to poke him. I loved the fact that he was able to be calm through the second poke all the way up until they went to put the cotton ball on with the band aid! What a trooper.

After his poke he wanted breakfast but couldn't have any because he was on a no-food order for his ultrasound. That contributed to his Monday mood, which was getting better and better! After that, I went in to the washroom for a moment and had closed the door enough that I couldn't see him on his bed. He had been glued to the bed all morning so I wasn't really worried about leaving him there for 2 minutes, but I guess I should know better with Peyton! I heard something outside the door and went to open it only to find him standing outside the door waiting to scare me. Normally this would not concern me but he has a pick line in his left arm where he has had 4 IV lines hooked up until just recently and if he pulls it I can only imagine what would happen (the line goes up his arm vein into the cavity near his heart!). Providentially, we had unplugged the machine from the wall earlier to go for a walk and I had forgotten to plug it back in! He had toted his IV machine all the way around the bed over to the washroom without even a peep. (He wouldn't get out of bed for the planned walk 30 minutes before that for anything.) As I looked out the door through the crack he was allowing me all I could see was taut cords! Arghhhhh. Needless to say, you can imagine the combined relief and amusement I felt when I saw what he had done and that everything was still attached as it should be. I think we turned a corner over the weekend and though he still has quite a ways to go it feels like he is going forward now.

He started walking over the weekend, usually in pursuit of a blue popsicle. He looks so adorable and yet so vulnerable when he's walking, hunched over and a bit like a cowboy who's been riding a horse for 24 hours straight. One of his little playmates was up to visit yesterday and it was amazing what that did for his spirits and capabilities. He took off with his surgery-induced gait and I had to work to keep up with the IV pole. We had a very short window of being able to keep up with him! He took a step back this morning and was hurting to walk again, but I'm sure we will take two steps forward again soon.

We were due to get that aforementioned ultrasound today to determine how the 3 abscesses they found last Thursday are doing but they had to postpone it to tomorrow morning. The surgical resident that visited this morning mentioned it's very uncommon for the antibiotics to eliminate abscesses, but that's what we are still going to hope for. It looks like Peyton may be here for a while still.

I have had many opportunities to reflect during this visit and part of me is grateful for this opportunity to walk the same halls, go through many of the same routines and talk to many of the same caregivers. It has allowed me to recall memories of Drew that might not have surfaced otherwise. I am thankful for the reminders of him that draw me closer. I was listening to a song this morning that brought me a smile in spite of the bumpy start. It's from the Quest for Camelot soundtrack and it's a song called On My Father's Wings by the Corr's. Their words are, "I will fly on my father's wings To places I have never been There is so much I've never seen And I can feel his heartbeat still And I will do great things On my father's wings." It's sung in the movie by a young girl who lost her father, but as she sang it my yearning ears only heard, "I will fly on my baby's wings, to places I've never been. There is so much I've never seen, and I can feel his heartbeat still. I will do great things on my baby's wings." It made me think of all the places I will see and all the things I will feel because of my baby's wings, and also of all the goals my heart will make with the inspiration of my baby's wings. I love you forever Drew!

Thank you for upholding our family with prayers, visits, meals, and support - we would be lost without you all!

Here's the thought that's been going through my mind this week, "I have raised you up for this very purpose, that I might show you my power and that my name might be proclaimed in all the earth." Exodus 9:16