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2/15/07 (Thursday)

Thursday, February, 15  We are up with the roosters, dogs and trucks again this morning.  Their alarm clock is very dependable.  They start about 5 and continue on until the sun comes up and the world is fully awake.  Our day is soon to begin with the variety of surgeries scheduled.  Yesterday the schedule was all hysterectomies.  Today we have a variety of cases that will keep us challenged…along with the heat and humidity.  Starting early has been better for me than before.  In previous trips we would not really get started with our surgery until 9 or so.  That made the day run well after dark to get through the surgery schedule.  Starting our surgeries at 6 allows us to see some daylight at the other end of the day.  Jane usually makes the rounds on the post-op patients while Greg and I are getting around for the day.  That has made the process speed up also.   Our post-op patients are all doing well except for one.  This lady was the Chachi Indian who came in Monday unannounced and we added her on to our schedule.  She has not had the quickest return of bowel function and has had some nausea.  We do see her outside walking around and she is making slow progress.  Jane hopes to send her home today or tomorrow.  The others have been going home on the second day post-op. 

Father, I dedicate this day to You like every other day.  We so much depend on You to do the work You have called us to do here.  You have walked here to San Lorenzo to serve the people here and draw them unto You.  You have asked us, urged us, to come with You here and help with this work.  What a privilege it is to be an extension of Your healing hand as we help these people with their health problems.  Thank You, Lord, for this opportunity.  I ask Your blessing on this day and on our work.  I ask for Your strength and power to uphold us and keep us healthy and help us endure the work that we face.  I especially ask for wisdom to make the right decisions as we care for these people.  Thank You, Lord, for Your presence here.  I give You all the praise.  Amen.  Greg and I joined Jane in making rounds as the anesthesiologist had not arrived yet.  Our last patient from yesterday was doing well.  In fact, all are doing well, including the Chachi Indian from Monday.  This last patient from yesterday has an eye muscle problem, likely something that has never been treated.  The eyes diverge with each eye looking off to the side instead of on center.  She seems to use both eyes when she talks to you.  Instead of moving her head, she seems to look out the other eye.  I commented to Jane when we saw her in the clinic that she was the first person I have met who faced both of us and could look each of us in the eye at the same time.  It was weird in that when someone’s eyes lock with yours you sense more than eye contact.  It’s like they are peering into your being, your soul.  When we talked to this lady Jane and I sat side by side and she seemed to lock eyes with both of us at the same time.   As we arrived to the clinic we met our lady from yesterday who failed to show up.  She was able to find the money she needed for the surgery and was excited to be here and get her surgery.  The others who were scheduled had not appeared yet so we will move ahead and take care of this lady from yesterday.  Angela Quintero, age 42, has had a one year history of left lower quadrant and left pelvic pain.  She has had 14 pregnancies with 10 living children.  She has a very tender uterus on exam with some tenderness to motion of the uterus as well.  Her left ovary was normal on exam.  I suspect her left-sided pain is originating in the uterus and radiating to the left.  We are planning a hysterectomy and will evaluate the left ovary and remove it if it shows disease.  Her pain pattern suggests chronic pelvic inflammatory disease.  At surgery we found an enlarged uterus but no evidence of any infection or other disease.  We took out her uterus and left the ovaries.  Her surgery went very well with minimal blood loss.  Rosalba Nazareno, age 69, came in complaining of burning pain in the pelvis.  She stated it starts in the external genital area and radiates into the pelvis.  She had a bladder repair in 2004 and had recently been told she needed a hysterectomy.  On exam her main point of tenderness was the uterus.  Palpating the uterus was quite painful for her and reproduced the pain she described.  The uterus was small as one would expect at her age and was basically normal except for the exquisite tenderness.  Our plan is to do a total abdominal hysterectomy.  This surgery was the quickest of the week, 40 minutes from skin to skin.  The uterus was small and normal appearing with no specific disease noted.  We took out the uterus and ovaries.  I suspect this will take care of her pain. Our next patient had come in late and was told by the people waiting for surgery that we were going ahead and she would not be able to get her surgery until late in the day.  She apparently left crying.  Maria Luisa called her and told her to come that we were waiting on her.  We waited about 45 minutes and then when she didn’t show we went ahead with the lady with the gall bladder.   Gladys Cuello, age 54, presents with right upper quadrant abdominal pain for 20 days.  An ultrasound revealed a gall bladder polyp.  She has fairly classic gall bladder pain and symptoms.  Her exam reveals normal findings in the right upper quadrant with no point tenderness.  She is also diabetic and has a fasting blood sugar of 195.  She supposedly takes a pill every day for the diabetes.  Because of her symptoms Jane plans to remove her gallbladder.  I assisted Jane and Greg passed instruments.  The surgery went well and this should relieve the patient’s symptoms.  During the surgery I became really hot and sweaty.  I think it is because I am low on fluids.  It is hot in here today as well.  I made it through the surgery and then had a couple drinks of coke and water and feel much better.  The lady who wanted the tubal ligation still hadn’t shown up for surgery so we are moving along with our schedule.  Our next patient, Doris Gruezo, age 27, is a senior medical student and has multiple uterine fibroids.  She wants to conceive and came to us to have a myomectomy procedure.  Her menses are regular and heavy.  She has had one previous pregnancy that ended with a miscarriage.  On exam she had a uterus that was grossly distorted with fibroids, one 3 cm on the anterior wall and another 3 cm one in the right cornual area.  This one was fairly tender.  Our plan is to remove the two obvious fibroids and hopefully not enter the uterine cavity.  I am concerned about the position of the one on the right in that it could be involving the right tube.  I don’t want to leave behind a scar that could block that tube and create more trouble conceiving.  At surgery we found 4 fibroids that were distorting the uterus.  Also, she had some filmy adhesions around the tubes and ovaries and both tubes showed evidence of previous inflammation.  The right tube was blocked at the end of the tube.  The left tube likewise was blocked at the end of the tube; however, about a third of the way toward the uterus there was an opening into the tubal canal.  I don’t know what may have caused this.  Theoretically, this could have happened from a previous ectopic pregnancy that ruptured through the tube at this location and then spontaneously resolved.  At any rate, we decided to do a cuff tuboplasty first to see if we could open the tubes and leave her some chance of pregnancy.  If the tuboplasty could not be done, then there was little merit in removing fibroids from the uterine wall.  On the left side I enlarged the small opening that was already present and did a cuff tuboplasty there.  We decided to not open the end of the tube because that could increase her risk for an ectopic pregnancy significantly.  On the right side I was able to do a cuff tuboplasty and leave behind what appeared to be a fairly healthy tube.  I had brought along my surgical loupes, glasses with 4X power magnification built in.  This is like working through a low power microscope.  Having the magnification really makes the tuboplasty easier.  Once the tubes were open we then removed the 4 fibroids.  There were two smaller ones in the anterior wall of the uterus.  Each of these were about 1 to 1.5 cm in diameter.  In the left upper corner of the uterus was a 2 to 3 cm fibroid projecting off the surface.  In the posterior wall near the cervix was a 4 cm fibroid.  Each of these came out without much difficulty and we did not enter the uterine cavity.  The uterus was back to normal size after the myomectomies.  I hope this does not set her up for a tubal pregnancy sometime.  That could be a disaster.  Jane will consul her to not attempt to conceive for 6 months and when she does conceive she is to make sure she is seen and an ultrasound obtained to locate the pregnancy and make sure it is not in a tube.  A ruptured ectopic or tubal pregnancy is a disaster and the lady can literally bleed to death.   It is now 3:45 PM and we are getting ready to start our last patient on the schedule.  The lady who went home and we had called to come back still hasn’t arrived.  If she doesn’t come soon, we will finish with this last patient.  Marcia Betancourt, age 48, is the mother of Doris Gruezo.  She has had a hysterectomy 7 years ago for fibroids and bleeding.  She complains of chronic back pain and left pelvic pain.  She did not lose her ovaries with the hysterectomy.  On exam she had tenderness in the left lower abdomen on deep palpation.  Also on pelvic exam she had a tender mass that was slightly mobile and was situated on the left pelvic wall.  I suspect this is her left ovary.  It would not be surprising that she would have adhesions involving that left ovary.  We plan to do an exploratory laparotomy with probable removal of the left ovary.  At surgery we found the left ovary involved in several adhesions with the omentum making a mass that would likely be painful.  The right ovary was absent.  We took out the left ovary and cleaned up the adhesions.  I suspect this will alleviate her pain. Ana Rivadeneria, age 34, has had 4 pregnancies was scheduled for a tubal ligation and a Burch urethropexy.  She has a prolapse of the vagina.  On exam I found an urethrocoele which will often be part of the prolapse and can lead to incontinence.  Fortunately, she does not have incontinence at this time.  She is late for her period so we asked her to do a serum pregnancy test.  If this is negative, we will proceed with the tubal ligation and also do a Burch urethropexy to correct the urethrocoele.  However, she left this morning and did not answer the telephone calls trying to contact her and did not return to the clinic.  Thus, we called it a day. Father, thank You for a good day.  We had some difficult surgeries, especially the myomectomy.  I pray that what we did to help her doesn’t cause her more trouble with adhesions.  Please place Your healing hand upon her and protect her.  Lord, I pray for the other ladies we cared for today.  Please encircle them with Your unfailing love and healing power.  Thank You for Your presence in the operating room today.  Thank You, Lord, for all you do for us.  I give You the glory and praise for what we have accomplished for You today.  Amen. 

It is 5 PM and we are back to the house for the evening.  As we were walking out Marjori, the patient that we operated on in September and were so concerned about her bleeding, was standing in the entry.  She looked great and told me she was feeling very good.  It was good to see her.  She had communicated to me through Jane about bringing a camera like mine as she and her husband wanted to buy one.  They assured me they would stand behind the price.  I was concerned that the camera would be far more expensive than they could afford.  When I communicated the price, they stated they wanted to go ahead and get the camera.  So I ordered one off the Internet and brought the new camera with me.  Jane talked with the family tonight and they paid for the camera.  Father, thank You for this good day.  The air is cooler tonight and that feels good.  Thank You for watching over our patients and caring for them.  You only are the source of hope, peace and joy.  Thank You for allowing us to participate in delivering some of that for You.  Amen.

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