Wednesday, September 4

    Today was quite a remarkable day. We started surgery this morning with one of the patients I had been told about before we arrived: Jacob, a 6 year old boy with a huge abdominal tumor, which was thought to be a Wilm's tumor or nephroblastoma. It is a pediatric cancer which arises  from the kidney, and can involve both kidneys. In this case, ultrasound examination had shown that only the right kidney was involved.
     We thought it was large when we examined him, and it seemed even larger once he was asleep under anesthesia. When we opened his abdomen, we realized that it was massive, extending from his diaphragm down to his pelvis, pushing his liver over to the left. These tumors are typically very vascular, and Jacob was typical in that respect. We lost a lot of blood, which was replaced, but his blood pressure dropped perilously low on several occasions; at those times, I could feel the faint pulse of blood in his aorta, worrying that it would stop at any moment. Fortunately for us, we have an anesthesiologist with us--Dr. Tom Feinberg from the University of Arkansas--and he did an incredible job keeping Jacob going. The Liberian nurse anesthetists, and particularly Mr. Anthony Hne, are wonderful but I doubt Jacob would have survived if Tom wasn't there. After we removed the tumor, there was persistent oozing from the right lobe of the liver where it had been attached; eventually we decided to pack the liver with a sterile towel, and we plan to return to the OR with him in 1-2 days to remove it and make sure all is ok. He was under anesthesia for about 4 hours, and probably had his blood volume completely replaced, but he woke up and was quickly able to be extubated. I don't have illusions about his long term outlook: the tumor is likely to recur, unfortunately. But perhaps we have given him some time in which he can feel better than he has for the past year.
     There were many times during the operation, particularly at those times when I thought we were going to lose Jacob on the OR table, when I wondered why I had ever agreed to operate on him. But the sad fact of life is that he had no other options, and therefore, in my mind, there wasn't a choice. If we didn't operate on him, he would have died fairly soon from this huge expanding mass in his abdomen, which had already caused him to lose weight and become listless. With surgery, and good luck, and prayers, and whatever else, he at least has a chance to enjoy life for whatever time he has left.
     We did more cases after Jacob: Jonathan and John did an acute abdomen which was thought to be appendicitis but which turned out to be a perforated ulcer; we had a 15 year old with a retained Foley catheter in which the balloon wouldn't deflate, so we used ultrasound to see the balloon and a spinal needle to pop it; and then Johanna, the PGY-3 from MGH, and I did a biopsy on a weird clavicular mass in a 17 year old girl.
    After finishing, we went to see Jacob, and he looked amazingly good: awake, responding to me, and stable. His father was there, and asked if he could see the tumor we removed; he was happy settling for seeing pictures of it. I am worried about Jacob overnight, and a part of me wanted to park myself at his bedside for the night, but I think he will be okay.
     For dinner we went to Sajj where we had a delicious Lebanese meal, and enjoyed listening to some live jazz. As Diego noted, what an amazing day it was spanning between Jacob and the jazz. I feel exceedingly fortunate to be able to have these experiences.