10/14/08 (Tuesday)
7:30 AM. I awoke about 4 and then dozed off and on until a little after 5 before getting up for the day. After the usual wake-up shower I felt more refreshed and clean. Even with the fan running all night with the air blowing on me, I still sweat a lot and smell like it. The shower is an absolute necessity for me, and probably for everyone else who would be in the same room with me. Jane and I started rounds at 6:20 and our four patients from yesterday were doing fine. One lady who had a hysterectomy was begging to go home this morning. She is not quite 24 hours our and she is up and about, eating, and ready to hit the road. The lady with the radical hysterectomy looks great this morning. She has minimal pain and is eating. I suspect she will go home later today or at least tomorrow. Our last hysterectomy also is doing well. She is about 12 hours post-op and is in a little more pain and having some dizziness and nausea. I am not surprised with this at this stage post-op. The young lady who had the least of the surgeries, the small mini-laparotomy that was just a look-see, was complaining of pain and whining a lot. I remarked to Jane that I have seen this reaction repeatedly. Those with the least amount of surgery sometimes will have the most complaints post-op whereas the people with major surgery seem to get along just fine. Also, I see the tolerance of pain here in Ecuador much more of a factor than in the US. At home we have to grade the pain and the expectation is that the patient will have no pain whatsoever. Thus, the patients are treated with all sorts of pain control that clouds the mind and slows the return to normal function. If the pain is not completely controlled, the patient has a bad experience and grades the care givers lower. Here in Ecuador, the people live with pain all their lives and they get along in spite of it. They require very little in pain management and are up and about quickly. The one lady this morning is a good example. She is ready to go home at 24 hours post-op. She climbs out of bed easily and moves about as if she did not have any incision on her abdomen at all. The difference is remarkable. I believe the Ecuadorians could teach the Americans something about pain and how to deal with it.
Breakfast was deep fried yucca cakes filled with cheese. They were actually pretty good. We all eat together in the break room and enjoy conversation and devotions. Today we had devotions based on the first chapter of James and then sang some songs together. Of course, it was all in Spanish so I didn’t get much of the conversation. However, it is fun just to sit in and be part of the group. Once breakfast was over we moved to the OR to prepare for our first patient. By 7:50 she was asleep and being prepped for the thyroidectomy.
Our first patient is a 30-year-old lady with an enlarged thyroid. She reports difficulty with swallowing and breathing. The thyroid is not that big based on other goiters Jane has seen. However, because of the symptoms Jane is going to do a subtotal thyroidectomy. The surgery went well although it took over 4 hours to complete. I broke away from the table when it was time to close the skin. Standing in one position for that long resulted in a lot of pain in my feet, especially the heels, and in my knees. We have three more cases this afternoon so Jane told me to take a break and get my feet up for a while. I didn’t argue one bit. The thyroid dissection was tedious and in Jane’s hands, safe. We had very little blood loss and she isolated the laryngeal nerves on both sides to keep them from injury. Injury to these nerves could result in paralysis of the vocal cords that could forever change the voice. We also needed to find and isolate the parathyroid glands that are important regulators of the calcium balance in the body. This type of surgery is tedious, slow, and methodical. The important part is to control bleeding by finding and ligating the vessels before they bleed and to remain safe at all times. This is what makes Jane such a good surgeon. She is always safe and respects the tissue so well. I believe that is why her patients recover so quickly.
Our second patient is a young lady, age 29, with a history of some pelvic pain. She said she got hit in the abdomen while playing soccer and then came in to see Jane. She also had had a positive pregnancy test and then thought she lost the pregnancy. The pregnancy test then became negative. Jane examined her finding a mass in the pelvis. An ultrasound also confirms the presence of a mass. She has an elevated CA-125, which is a tumor marker that goes up with ovarian cancer. It also can elevate some with bleeding and inflammation in the pelvis and from some benign situations in the pelvis. Based on this lady’s age and the recent pregnancy, I wonder if she had an ectopic pregnancy (tubal pregnancy) that may have bled and developed a mass in the pelvis and then stopped bleeding. This would elevate the CA-125, cause pain, and create the symptoms she describes. Once she was anesthetized with the spinal anesthetic, we did an exam under anesthesia. The mass was connected to the uterus and felt very much like a large fibroid. This would also explain the symptoms and how this lady presented. Once we opened the abdomen we found the uterus involved with a large fibroid on the left side projecting into the broad ligament and a small one in the right broad ligament. We talked with the patient to make sure about her desire to keep the uterus. She said she did not want to lose her ability to conceive. Fortunately, both of these fibroids did not involve the uterine wall or the tubes. We were able shell them out of the broad ligaments and close the site without any compromise to her uterus, tubes or ovaries. I was very pleased to be able to accomplish this for her. Broad ligament fibroids are quite unusual, especially as the only ones. While we were operating Maria Luisa came to the head of the table and began talking with the patient. When she prayed with her before the procedure started, the patient cried. Maria Luisa talked more with her and in the process of doing the surgery led her to the Lord. The patient gave her heart to Jesus Christ in the middle of her surgery. This is so special to be part of the process that brings eternal life in the presence of God to an individual. Thank You, Lord, for this lady. You prepared her heart and drew her to You. Thank You for giving her the gift of eternal life with You. I praise You today! Amen.
3:30 PM. We broke for lunch and enjoyed a wonderful meal of rice, lentils and fried fish. The fish was delicious. Typical Ecuadorian fashion, the mid day meal is the largest. The evening meal is usually a bowl of soup or something light. We have two more surgeries to go and it is almost 4 PM.
The third patient is a 69 -year-old with uterine prolapsed and a cystocoele. She has normal bladder function but does not like the feeling that something is falling down. On exam she had rather prominent prolapsed and a large cystocoele. We will do a vaginal hysterectomy and anterior repair to restore the anatomy. This surgery went very well. The candy cane stirrups allowed much better exposure and Jane and I could work side by side easily.
The fourth patient is a 54-year-old with a large cystocoele. Her bladder drops out and consequently, she has to stand to urinate to get the stream to flow. She does not have any incontinence. On exam I could feel a defect in the supportive fascia on which the bladder rests. Fixing this should correct her problem. There is no uterine prolapse involved. We will do an anterior repair and closure of the fascial defect. The surgery showed a significant defect in the fascia that repaired very nicely. This repair restored the normal anatomy and the bladder resumed its normal position.
We are finished for the day. It is now a little after 7 PM. It has been a long day on the feet and I am tired. Bed will feel good tonight. Tomorrow is another big day for us. My ankles are swollen from standing all day and the knees are stiff and sore. Jane and I will start early with rounds so we can be ready to eat breakfast at 7 and start our surgeries at 8. Vivianna, our anesthesiologist, is trying to learn more English so she attempts to talk with me in English and wants me to help her. At the same time she is trying to teach me some Spanish. We are learning together.
Father, it has been a good day. Especially great is another soul who has received eternal life with You. Heaven rejoiced again today, Father, and I know You must be quite happy. Thank You for the privilege of being part of the harvest. Lord, thank You for protecting our patients and giving us the stamina and wisdom to do the right surgeries. I pray for our patients, Lord. Please bring them comfort and peace. Allow Your healing power to control the recovery process. Thank You, Lord, for Your unfailing love. Amen.
Medical Missions 
Marvin,
Thank you for the wonderful word pictures of the surgeries and the people. Linda and I were talking today how much we wish we were with you.
I can’t get the people of San Lorenzo out of my thoughts and prayers. They will be with me always. Praise God for the new souls added to the kingdom. You, Jane and the others are doing a mighty work for God.
Tell everyone how much I miss them. My prayers are with them each day.
Love and blessings,
Annette
I pray God touches your body, refreshing it after such a strenuous time–and with much more work ahead of you. Thanks for taking the time after such a long day to patiently do these blogs. I am being blessed by the ability to follow your days so carefully.