Monday March 11

The beginning of our second and last week on this trip. On rounds it was nice to see that the man who wouldn't wake up on Saturday night Is doing well.we sent several patients home, and then went to Grand Rounds where the Internal Medicine team presented statistics for the past year. One of the interesting ones was that sepsis has the highest case fatality rate of all; not surprising in view of the late stage at which many patients come to the hospital, and the rather modest resources available to treat them. Then to the OR where Santiago and I did surgery on Victor, a 12 year old boy who presented in early January with an acute abdomen. At surgery he was found to have perforations of his ileum and descending colon; the colon was repaired and the ileum brought out as a loop ileostomy. He got better, and in February had his ileostomy decommissioned by a visiting American surgeon. He went home, and came back a few days later with peritonitis. On March 1 Moses did another laparotomy, washed him out, found the ideal anastomosis had broken down, and gave him another ileostomy. We saw him first a few days ago when the intern showed us his wound was breaking down, and stool was coming out a small hole near the ostomy. We really didn't want to reoperate on him, but felt we had no choice. Today we found an abscess, with obstruction, and a fistula. We took it all apart, and resected the distal several feet of ileum and cecum. Knock on wood it went well ! Santiago and I like to do one case together each trip, because it reminds us of the old days when he was a resident, and it also reminds us of why we enjoy doing this work together. The next case was a thyroidectomy for goiter with John. I thought maybe we could get away with just taking out the huge left lobe and isthmus, but the right lobe was nodule and I knew the right thing to do was to take it as a subtotal. Then we were going to do a cholecystectomy, but we were told about a 9 year old boy named Alvin admitted today with abdominal pain and dissension, and positive for typhoid. He was looking quite sick, so Santiago and Nathan brought him to the OR for a laparotomy; they found a lot of fluid in his abdomen, and 2 distinct perforations. They were working away when he became unstable, and eventually coded. We tried to resuscitate him for about 45 minutes to no avail. It seems like we experience the death of a child on every trip, but it doesn't get any easier. I know it is part and parcel of the work we do, and that we have a lot more successes than failures, but it still hurts.