Tuesday March 11

Tuesday March 11

1 year old LIH
Femoral hernia
RTA head and neck lacerations
R lobe thyroid
Parotid
Ex lap and washout

       We had another relatively busy day today, but thought we would finish early until the last case came along. We started with a 1 year old boy with a hernia while Santiago was doing a femoral hernia repair. Then they brought up a man who came into the ED comatose a few days ago; the story was that he was a pedestrian struck by a motorbike, but the ED physician thought that story was bogus. In any case, the said his GCS was 3 when he arrived ; he had an open skull fracture, a neck laceration, and a fractured humerus. Over the course of 2 days, he wakened from his coma, so I guess they thought is would be reasonable to repair the lacerations, and thus we became involved. Due to lack of beds, he came from the Trauma ED to the OR for the repair, and then was returned to the Trauma ED. Weird system, but it sort of works !  Next on the docket was a parotid mass for me and Yuk and a thyroid mass, probably cancer, for Santiago, Rakesh, and Konneh.
       The final case was a 40 year old man who had presented 2 weeks ago with an acute abdomen and was operated on by Dr. Konneh, who said he found a perforation of his cecum, and another in his sigmoid colon, presumably due to typhoid. But he also said there were patchy areas of necrosis on the anti-mesenteric border of the colon, and he didn't know what the significance of that finding was. We had seen him in his bed on a regular basis since we have been here; he wasn't going downhill, but he also wasn't progressing the way we thought he should be. Intuition remains a critical element in medical and surgical decision-making here, in large part because there is often no way to confirm a hunch. Santiago and I had talked almost daily about whether this man needed another look inside his belly, so yesterday afternoon I went down to see him. The nurses said he was eating and getting out of bed, and I was thinking maybe we could continue to hold off on further surgery. I asked Diana, the head nurse on the surgical ward and very clinically astute, what she thought, and she said we should take him to the OR. So we did.
       Santiago and Yuk found an ungodly mess with abscesses, another perforation, and necrotic omentum. He ended up doing a total abdominal colectomy. Philomina was superb with his anesthesia, giving him blood and fluids over the 3 hours of operating. He was intermittently hypotensive during the case, and then he just didn't want to wake up and breathe on his own. This year, in contrast to last year, they have a ventilator at JFK so he was transferred there for overnight observation.
        We went to have our dinner at the dorm around 10 pm, and then stopped at the ICU to see the last patient. He was very cold, and obviously in critical condition; we left around midnight with our fingers crossed.