Thursday September 5

      I had a restless night listening to the generator and the rain, and thinking about Jacob. Perhaps there was a reason for all that, because when we went to Pediatrics as our first stop this morning, we saw that his bed was empty. The nurse told us that he passed away around 2 am. According to the nurses notes, he was doing well at 11:30 pm; sometime later his mother told us that he asked for some water to drink (she told him he couldn't have any), then he asked for his father. Soon after that his breathing became rapid, and soon after that he expired. His mother and father, and other family members were there when we arrived; his mother asked to see a picture of the tumor, and she took a picture of the picture with her cellphone.
        My guess is that he died of hypovolemic shock because his fluid requirement was larger than the pediatric nurses realized, but who knows for sure. Part of me feels totally defeated by such cases; on the other hand, we gave him the only chance he had for a better life at least shortterm, but it wasn't to be.
      To start this day Diego and I operated on a 38 year old woman with obstructive jaundice. She was here on the Medicine service, and then was sent to Tappeta for a CT scan; that show a stone impacted in his distal common duct. We planned to do a cholecystectomy and common duct exploration, and we had scavenged around yesterday looking for the appropriate tools. After much effort, we found that we could not pass anything through her distal common duct, and so we ended up doing a choledochoduodenostomy. I am  hopeful that she will do well, and I see no reason why she shouldn't, but an experience like Jacob can make you a bit gun shy, It was another 4 hour operation, and required quite a lot of creative thinking since we didn't have the usual armamentarium of tools and assists we have back home. I enjoy that challenge over here, and at the end of the operation I felt pleased that we had met the challenge and done well.
     While we were doing that, Jonathan and John were busy with an emergency incarcerated umbilical hernia in a 2 year old, and then a colostomy decommissioning in a 29 year old. At the end of the day, on our way out, we stopped in the Pedi ER to see a 2 month old boy with abdominal distension. He was born at 28 weeks and has a twin sibling, so effectively he is just at term now. He stopped eating on Monday, and now he little abdomen looks like he swallowed a balloon, and yet he didn't seem to be that tender. We examined him, and ultrasounded him, and eventually decided that we should watch him overnight. I'm not sure what going on in his belly, and so I'm not sure it's a problem that needs surgery to fix; I am sure that an operation would be hazardous for him if he doesn't need it.
     After dinner at the house, I went with Dr. McDonald to see my private patient who is doing well. Then back here to bed.