10/13/08 (Monday)
Heaven Rejoices!
6:30 AM. Last evening when the conversation lulled and we all mentioned it was soon time to go to bed, I went to my room and prepared for that very act. I was tired and it was dark and I thought it felt like 10 PM. I then looked at the travel alarm and it said about 8:05. I thought it was completely wrong so I checked my watch only to confirm that this time was correct. It just seemed odd to be tired and ready for sleep when I had a good nap in the afternoon and a good night’s sleep the night before and now ready for bed at 8 PM. However, I listened to my body and not my logic and went to bed anyway. I awoke this morning about 5:30 and could have spent a little more time in bed. However, I got up, showered, which was the actual wake-up call with the cold water, shaved and got ready for the day. We meet at 7 for devotions and breakfast so I thought I could have a little extra time to do some quick laundry in the sink and read. Also, I wanted to start on today’s journal entry since I will probably not be able to access the computer until late tonight after our long day in the OR. One patient we will operate on today has cervical cancer. Jane saw her and made the diagnosis and feels the cancer is very early since there is no evidence of any spread on clinical exam. I have not had the opportunity to examine her yet since she is coming from a long distance and was planning on arriving on the day of surgery. The other option is to send her to the cancer hospital in Quito; however, that option is not available because this lady does not have any money and certainly cannot afford to go to Quito for treatment. Her only chance is to have the surgery here with a hysterectomy. Otherwise, she would just have to live with her disease and die from it. If she doesn’t have the money to pay for her treatment at the cancer hospital, she won’t receive any treatment. This is where the culture is different compared to the USA. We treat everyone regardless if they have the money up front or any insurance. Because of that we do a lot of charity care and spend a lot of resources just to care for these people. However, I feel this is right because the person is far more valuable than any of the resources. In Ecuador, it seems the attitude is different. The care you receive depends on how much money you have. If you can’t pay for the treatment, you don’t receive the treatment. I certainly hope this patient we will operate on today has disease that we can remove cleanly and not leave any cancer behind. I don’t have the option of a frozen section to determine if I have all the cancer removed. I don’t have the option of all the support services we have at home when dealing with this problem. We have to make a judgment based on our clinical findings only and go from there.
In 2004 on my first trip here I did a hysterectomy on a lady who lives across the street from the clinic. She had a large cancer of her cervix that periodically would bleed very badly placing her life in jeopardy just from blood loss. We did the hysterectomy only to save her from bleeding to death and I felt very inadequate in being able to free her of the cancer. It is now over 4 years later and she is alive and well and showing no signs of recurrence at all. I saw her yesterday working out in front of her house across the street. It thrills me to think we may have cured her of her terrible disease. Yet, we were flying by the seat of our pants, so to speak, when it was time to make the decision on what to do for her. Those conditions have not changed. We still are flying by the seat of our pants. I believe this is the art of medicine, knowing what to do without all the supporting evidence and systems to guide you better. A good friend and colleague at home stated that “medicine is an art that uses science as its vocabulary.” I think that states this profession very well. We rely on science very much and it is very important; however, there are times when the decision must be made based on the art, not the science. When the science is not available or incomplete, that is when you must employ the art and realize you may be taking risks in order to achieve the treatment goal desired. If you rely completely on the science, you may be paralyzed in moving forward if the science is not totally there.
Father, thank You for the great night’s sleep! I feel so rested this morning and ready to start this day. Lord, thank You for what You have been teaching me from the books of Matthew and James. Thank You for the time I had yesterday to think and study and write. Thank You for the opportunity to come here and work with Jane and her wonderful team to deliver much needed care to the people we will see. Thank You for Dr. Mark Nelson and his willingness to serve You here this week. I so appreciate him as I appreciate all the other members of this team. Lord, I pray for today. I pray for the patients we will operate on. I pray for wisdom to make the right choices and I pray for clarity in what we see and find to know exactly what we need to do. Lord, protect these patients today. Wrap Your arms around them and hold them close to You and allow them to feel Your presence. Lord, also wrap Your hands around our hands and guide us through these surgeries. Father, I pray especially for the lady with cervical cancer. Please, Father, make it clear to us just what we have to do to help her and hopefully cure her. Protect her, Lord. Father, I pray for all the people back home who are praying for us today. Their prayer support means so much. I pray for my family and especially for Phyllis, my beloved wife whom You brought into my life 42 years ago. Thank You for her. She has been my best friend, my helpmate. She has made me whole. I love her so much and I thank You for bringing us together. Please embrace her today and in a special way show her Your love. Thank You, Father, for Your unfailing love for each of us. I love You, Lord. Amen.
7:00 AM. We met over in the break room in the new building for breakfast and devotions. Jane had put names on the lockers in the changing rooms and my name was there in Spanish…Dr. Islan. The spelling is because of the phonetics in Spanish and that is how my name would be spelled to sound the same as in English. We have 5 surgeries today, four hysterectomies and one ovarian cystic mass. Jane then informed me that the fifth surgery cancelled. This means we may be done before dark.
6:00 PM. We finished our day before dark, but not much. The day went well and all the surgeries went smoothly without any problems. While waiting for our anesthesiologist to arrive our first patient was in the operating room talking with Angelita and Maria Luisa. They prayed for her as is their custom and the lady then began asking questions about salvation. After some more discussion she stated she wanted to become a Christian and to accept Jesus into her heart. Maria Luisa and Angelita explained what this meant and she wanted to pray to have Jesus forgive her sins and to receive the gift of salvation. At that moment Angelita and Maria Luisa spent more time in prayer with her and this lady became a new member of the Christian faith. To start our week of surgery our first patient received spiritual healing first. We rejoiced with her over this decision and as the Scripture states, Heaven rejoices as well. The smile of peace and joy was all over her face and I feel she knew what she had done. Who knows what had taken place or who had even planted the seeds that brought her to this point today. Maria Luisa gave her a Bible so she could have one of her own and sat and read Scripture to her until the anesthesiologist came.
Thank You, Father, for this moment. Thank You for reaching out to this woman and changing her heart. Thank You for the incredible gift of eternal life You provide to anyone who will accept this by trusting in You and accepting Your Son, Jesus, into his or her heart and life. Thank You, Lord! Amen.
Our first patient was 46 and had been having a lot of heavy bleeding and chronic pelvic pain. She works as a clam digger, a lowly job that involves long hours of wading in the water digging in the sand for clams. The pay for a day’s work is a dollar or so. She had a bruise on her hand that was sore. She said she was digging for clams and a big fish bit her hand. The heavy bleeding has been a problem in that when she is on her menses she cannot work. This cuts her out of income for several days per month. Jane recommended a hysterectomy to manage the pain and bleeding. Her health otherwise was good. At surgery we found multiple uterine fibroids and some adhesions of the tubes and ovaries. We performed a complete hysterectomy including removing the tubes and ovaries without any difficulty. I would expect she will feel much better once she recovers from the surgery.
While we were waiting for the second patient a lady came in with sudden abdominal pain. She was pregnant and had been coughing a lot this morning and then experienced some intense pain in both lower quadrants of the abdomen. I checked her and found her to be about 26 weeks size with active fetal movement. The uterus was not tender but she had pain and tenderness over each round ligament down to her groin. I suspect she was having spasm of the round ligaments because of the coughing. We reassured her and she went on her way.
Our second surgery was a 66 year old lady with a history of cancer of the cervix. She had been seen at the SOLCA hospital, the cancer hospital, because of a bad pap smear. The physicians there told her she needed a hysterectomy. If the patient decides to have the surgery somewhere else, the physicians at SOLCA will not send any reports or information along with the patient. However, they did give this lady a copy of her last exam where the physician wrote that the biopsy of the cervix was not deep enough and invasive cancer could not be confirmed. Jane felt the cervix was normal and thought we could do a hysterectomy for this lady. I examined her once the anesthesia was in place and I agreed with Jane. If she had any cervical cancer, it was very early. We decided to do a modified radical hysterectomy. The surgery went very well. This lady was not heavy and her anatomy was not distorted. We were able to do a modified radical hysterectomy in 1 hour and 20 minutes. The uterus was quite small and the cervix did not show any evidence of a problem. Jane will be taking this specimen to Quito for a pathology evaluation. If this lady has any cancer, it is likely very early in its development. This surgery went very smooth and I was quite happy with the result.
Our third surgery was a 24 year old who came to see Jane because of pelvic pain. Jane found a cystic mass on exam and then obtained an ultrasound. The ultrasound showed a large complex cyst. A repeat ultrasound obtained a couple days later likewise showed this mass. When I saw her in the clinic I could not find any specific mass and I wondered if the cyst could have been a corpus luteum as a result of ovulation. The pain could have been a result of bleeding into a corpus luteum, something that will happen and give this type of picture. When she came in today we did an exam under anesthesia finding no evidence of a mass. Thus, to assure there was no cyst, we did a minilaparotomy to actually look at the ovaries. If the mass were still there, we could then enlarge the incision and deal with it. Fortunately, the ovaries were normal and there was no cyst or mass. This surgery went very quickly. At home this patient would have been evaluated with laparoscopy; however, that instrument is not available here.
The fourth surgery was a 44 year old lady with large fibroids and heavy menses. In fact she was on her period today and left pools of blood wherever she walked or sat. Her health is good otherwise. We did a hysterectomy removing a uterus that was the size of a 4-month pregnancy. This surgery will certainly allow her to go on with life and not have the troublesome bleeding. Her surgery went very smooth as well.
Our surgeries were completed by 5:30 PM or so. Overall it was a good day. Maria came in to help us by washing the instruments and surgical drapes and towels. She was able to keep up with our surgeries so Angelita and Maria Luisa do not have to do all this after the cases are done at the end of the day. In spite of her lymphedema, Maria moves around well and has this radiant smile that is infectious. She is so sweet and gracious. Her legs were wrapped to help control the lymphedema. She walks without assistance and is an inspiration to me on how to live in the face of a chronic and disabling problem.
Thank You, Lord, for a good day in surgery. We accomplished a lot today and Your hand was there the whole time. Especially I want to thank You for our first patient who received spiritual healing of her heart this morning. Lord, that was a miracle right before our eyes. You drew her to You and transformed her heart and allowed us to opportunity to see it happen. Thank You, Lord, for the guidance You give us, the support You give us, and the love that is unfailing for all of us. Thank You for Maria and the hope and joy that fills her heart. Thank You for allowing me to meet her and learn from her. I pray for her, Lord. Please guard her and help her. Father, I commit these patients to You tonight and pray for their safety and comfort as they recover from their surgeries. Thank You, Lord! Amen.
Medical Missions 
I trhankd God for your day of successful surgeries.