Wednesday September 11

    We received more sad news this morning: the 8 yr old obese girl with a ruptured appendix who had her surgery on Monday died last night. By report from Dr. Shankar, an excellent pediatric resident, she was fine and talking to her father at 6:30 pm. In the early morning hours Dr Shankar was called because her breathing was rapid and labored; he felt she needed fluids and he gave her a bolus, but about 10 minutes later she stopped breathing and could not be resuscitated. I think that she had some adrenal insufficiency, or other hormonal problem, that somehow contributed to her unexpected and sudden demise, but we will never know for sure.
   Another busy day for us in the OR, but we were limited to one room because Professor Golokai was operating today. Jonathan and John first did an adult hernia, and then Diego and I re-explored a 14 year old boy who was operated on for perforated appendicitis 10 days ago, just before we came. Apparently he did will initially, but lately has been going down hill. He has developed bilateral pedal edema, and blood work showed he has an acute kidney injury. He also has elevated liver enzymes, but that may be long-standing as he is known to have hepatitis B. This morning when I saw him he looked toxic, and clearly had a tender abdomen that needed to be opened. Upon doing so, we found an abscess near his cecum as well as another at the root of the mesentery. Perhaps the infection is the cause of his kidney problems, but I fear it is due to some other unknown cause; time will tell.
    During the course of the day we had several consults: one was a 6 year old boy whom Diego and I saw in the Pedi ED in the morning. He had been off food for a couple of days, and his abdomen was distended but not tender. We recommended IV hydration and observation, but when I saw him again in the afternoon he was significantly tender, so we decided to explore him for possible appendicitis. After Jonathan and Diego finished a thyroid, we brought him to the OR; on opening his abdomen we found a large volume of serous ascites, and evidence of mesenteric adenitis. Despite the negative surgical findings, I think operating was the right thing to do. We did take out his appendix anyway.
    Another consult during the day was a 17 year old female in the Maternity Hospital whom Johanna asked us to see. She had suffered a fetal demise at 7 months 2 weeks ago, and delivered the stillborn at home. She presented to the Maternity hospital with weakness, a distended abdomen, and a drop in her hemoglobin. An ultrasound showed a lot of abdominal fluid and a normal looking uterus. One of the maternity docs had aspirated some of the abdominal fluid and it looked cloudy yellow. John had the briliant idea of putting some of the fluid on his glove and smelling it; the odor was feculent. When we saw her, her abdomen was distended and firm, but it did not appear tender. It was a confusing picture, but We felt she clearly needed exploration. So she was transferred over, and Jonathan and Diego did her surgery. It was another Vesuvial abscess, this time recorded on film ! It turned out to be perforated appendicitis, and it could have been the cause of her fetal demise. How she managed to live with what was going in his her abdomen remains a mystery to me; she is another one for whom I have my fingers crossed.
     Another consult during the day was an old patient of Dr. Arruffat who had a low rectal cancer 2 years ago, and then further surgery for a stricture last March. She now appears to have a recurrence of her rectal cancer as well as a mass in her ascending colon seen on a CT done in Tapita. If this is true clinically, she probably needs to have her whole colon removed and a permanent ileostomy created. We gave her the option of having it done tomorrow before we leave, or waiting till March when we are back with Santiago. She wants it done now, so that is what we will try to do. Complicating the surgery is the fact that she is a Jehovah's Witness, and absolutely refuses any blood transfusions. This will be a huge challenge. Jonathan and I talked to Santiago in Indiana, and he is in agreement with our plan; I know he also wishes he was here.
    We finally finished around 10pm. We came home to have dinner and get to bed, knowing that our last day on this trip tomorrow will be a big one.