10/15/08 (Wednesday)
5:45 AM. I awoke from another good night’s sleep just before the alarm was to ring at 5:00. I must really be tired to sleep this soundly or maybe it’s the white noise from the fan that drowns out all the other interesting sounds in the night. At any rate I feel rested and refreshed. Awakening ahead of the alarm is one thing, really awakening in the cold shower is another. Lord, this is a new day, a day You provide for all of us. Thank You for setting all the events in motion so we can enjoy this earth and each new day. Lord, there is so much we don’t understand about how we happened to be here in the vast universe. Yet, this was all of Your creation. You thought this up and made it happen. And it’s perfect as only You could make it. Father, I pray for today. I pray for the patients we will care for today. I pray for our patients who are recovering from surgery. Thank You for Your healing power that is covering over them at this time. Thank You for the wisdom and the grace You give each of us to be able to carry out Your ministry here. Thank You for this opportunity You have given me to come here and participate in this medical outreach to this region of the world. Thank You, Lord.
I learned a little more about our cook, Esther. She is an older sister of Damarys; however, the two of them do not share any features one would expect of sisters. Damarys’ mother is a kind-hearted, gracious person who came across Esther when she was 4 years old. She lived in a remote village and was unwanted by her parents. Apparently, Esther was full of worms and had hair full of lice and was filthy. She lived as an outcast from her parents and subsisted on her own. Damarys’ mother loved her from the start and wanted to take her and raise her as her own. Esther’s parents said, “Take her. We don’t want her.” Thus, Esther moved in and became the first daughter of Damary’s mother by adoption. Esther became the older sister to Damarys and her younger sister. I praise Damarys’ mother for having the heart to reach out and save a young child. I just don’t understand how parents could toss aside a child of their own. The logic that brings them to that decision just baffles me. The child is a human life, a life that began from them. Yet, they treat that life like trash.
Last evening Mark and I had some time to talk more. He has been a full-time missionary with HCJB for three years and is working in Shell. Prior to that he worked in a family practice setting in Texas and was on the staff at Parkland Hospital in Dallas. He said Dr. Amy Dawson, a family practitioner who just joined HCJB and came from Fort Wayne, a good friend of mine, will be joining him at Shell at the first of the year. I plan to see Amy and her husband, Tim, when I return to Quito. They live in Quito currently. I told Mark about the Matthew 25 Medical and Dental Clinic in Fort Wayne and how Amy was the medical director of the clinic for a few years. I run a gynecology clinic at Matthew 25 seeing patients there one day a month. Matthew 25 Clinic was started several years ago by the medical community to provide health care for the indigent population. It is located downtown and now is quite the clinic with multiple services in medical and dental care. The clinic serves over 20,000 patients annually and has a great outreach to our community. Fort Wayne has become the haven for Burmese refugees and is now the center of the largest Burmese population in the US. Also we are seeing more refugees from Somalia and Ethiopia as we as Sudan. There is also a large Hispanic population in Fort Wayne. All these people receive care at Matthew 25 along with the uninsured people in Fort Wayne. This clinic is a mission outreach right in my own back yard.
Jane and I will soon start rounds on our post-op patients and then we will all meet at 7 for breakfast and devotions. We will then start our day of surgeries. We have 5 cases today and these hopefully will move along smoothly. 6:45 AM. Rounds are finished. The patients are all doing quite well post-op. Our two remaining patients from Monday are anxious to go home. They are up and around and voicing minimal complaints. Our patients from yesterday are all doing well. The lady with the myomectomy is having some incisional pain but is ambulating and getting along on pain pills. I am continually impressed with the tolerance these people have for pain, especially post-op pain. They all get along very well on what we would consider minimal pain control at home. These people generally will use a few Vicodin or Darvocet tablets only and in two days may still have most of the dozen tablets still unused. One tablet will sometimes last them all day. At home at this stage post-op the patients would still be receiving injectable pain medicine either through the IV or in a shot form. Generally, I could not get my patients to move to pain pills until the second or third day. What I see here is much more rapid return to normal function with bowels and bladder working quickly, eating regular diet and being up and walking.
7:45 AM. We ate breakfast together, had devotions, sang a hymn and now are ready to start our day. Our first patient is a lady with a large cystocoele. She is 47 and has had a hysterectomy in the past. She presented with a large cystocoele and enterocoele. The surgery went very well with repair of the large enterocoele and then I assisted Jane in doing the cystocoele repair. We were able to restore the anatomy allowing normal position of the bladder and upper vagina.
After this surgery Maria Luisa moved our surgical light when she stepped on an outlet in the floor. She was moving the light from where it had been positioned for our first surgery. It was sitting directly over a 220 volt outlet in the floor. As she moved the light her foot touched the outlet cover on the floor and she received an electric shock. Then the outlet in the floor smoked some as she moved the light away from this area. It smelled like burning insulation. We checked the outlet and it seemed okay and somewhat cool. However, it bothered me that the outlet was not grounded well. What apparently had happened was a grounding chain under the surgical light grounded the outlet as well as the chain passed over the metal outlet cover. This could have been very dangerous because of the higher voltage. I asked Jane why the electrician put two 220 volt outlets in the floor in the operating room. I assume it was for convenience; however, this floor is mopped all the time and is prone to have fluids spilled on it. These live outlets pose a real danger. We then went to the circuit breaker box and turned off the circuit breakers to those outlets so they are not live at this time. Jane said she will have the electrician look at these outlets. I recommended she have him take them out as it is very dangerous to have these in the floor when the floor gets wet a lot. Plus, right now this one outlet is not properly grounded.
The second patient is 19 and has a persistent left ovarian cyst. This has been present for the past several months documented by a couple ultrasounds. Our plan is to remove the cyst and save the ovary if at all possible. My hope is this may be a paratubal cyst by the way it looks on ultrasound. If that’s the case, the ovary would not be involved. Exam under anesthesia revealed a left sided mass separate from the ovary. Upon entering the abdomen, however, we found extensive adhesions from pelvic inflammatory disease with entrapped fluid in the left pelvis. This would explain the cyst seen on ultrasound. The ovaries were involved with multiple filmy adhesions as were the tubes. We cleaned up the adhesions to return the pelvis to normal as best as we could. The underlying disease of pelvic infection may result in more adhesions in the future. For now, there is nothing more to do. The chronic infection could likely result in difficulty conceiving in the future.
Our third patient is an 80-year-old lady who has had a hysterectomy in the past. She presents with total vaginal prolapse. In reviewing her situation and the difficulty of repairing this well, I felt this would be best approached abdominally with a bilateral paravaginal repair. This would correct the anatomy and help keep this problem from happening again. She is very short, about 4 ½ feet tall. The anesthesiologist was concerned about her lung capacity. While waiting for some change over in the OR I sat in the break room to put my feet up and then prayed for this lady, for protection for her, for wisdom for us. The anesthesiologist came to Jane and me and asked us to talk to the family to discuss the risks involved. We met with the family and had an extensive conference looking at the various options to manage this lady’s problem. We decided to take a safer approach surgically by closing the vagina from below to avoid entering the abdomen. This will be quicker and could be less overall risk for her. While we were talking with the family, Maria Luisa was faithfully witnessing to this lady and in the process led her to the Lord. This lady is 80 and finally after a long life was introduced to Jesus Christ. She now has a place reserved for her in Heaven. What a celebration! The surgery was a real challenge. We eventually did an anterior and posterior repair, and sacrospinous fixation. This took about 1 ½ hours to complete, much faster than I had thought. Exposing the sacrospinous ligament without the usual retractors and instruments for this was quite difficult. Fortunately, we were able to get a stitch in this ligament without initiating any bleeding. Her end result was reduction of the prolapse to a normal vaginal position. I think this will give her a good result. She tolerated the surgery quite well and we were able to stay out of the abdomen. This will help her post-op with her breathing. Thank You, Lord, for helping us with this surgery. It was difficult and a real challenge for me. However, I could feel Your hands around our hands and You guided us through it. Thank You for protecting this lady. She is Your child now and has a future full of hope. Thank You, Lord! Amen.
3:00 PM. We just finished lunch and will soon start the fourth surgery. During the last surgery I experienced a major spasm in my back that almost took my breath away. Every time I would twist just right, the spasm would grab me. It is on the right just at the lower area of the chest. In the past when doing surgery all day, all the leaning over and holding one position for lengths of time would create some muscle cramps. I haven’t had one like today, however. Our lunch was checking, mashed potatoes and a bean salad. When I finished with my piece of chicken, Maria Luisa wanted my bones. She took the bones and ate them. I had watched her eat the bones left over from her piece of chicken. She chews them up and eats all the marrow out of the bones. Jane said I am now one of the family since Maria Luisa felt comfortable asking me for my bones.
Our fourth patient is a sister-in-law of the fifth patient and a daughter-in-law of the third patient. She presents with classic stress incontinence and has on exam urethral descensus as her primary finding. She does not have a prominent cystocoele. We are planning a Burch on her as well. This lady was extremely nervous. She dressed in the hospital gown in a way we had never seen before. She had it on with her shoulders bare and all the ties across the back. It looked like an evening gown. We were able to do the procedure in 38 minutes. We got a good repair of the urethrocoele with the Burch sutures. This should give her a good result with clearance of her stress incontinence.
Our fifth patient is 48 and has a prominent urethrocoele with some stress incontinence. She is the daughter of the third patient. We are planning a Burch urethropexy. This way she will not need a catheter for any extended length of time post-op and should have a long-lasting result. She also has an annular scar in her vagina about midway up. This causes her pain with intercourse. We plan to do a couple release incisions in this scar to allow it to expand. Her health is good. At surgery we found a band of scar that released easily allowing relaxation of the constrictive scar. The Burch procedure was more difficult because of difficulty getting good exposure. Once Cooper’s ligaments were identified, the sutures were placed and we obtained elevation of the urethra and reduction of the urethrocoele. I am pleased with the result.
6:45 PM. Our day is done! It has been a long day with tired swollen legs and ankles and a recurrent back spasm. It will feel good to lie down, that’s for sure. My back hurts on the right side just below the scapula. If I take a deep breath or twist my trunk it will feel like a knife is going in. It was giving me a lot of trouble in the middle of the third surgery and has been frustrating me since.
Tomorrow, our day again is long but the surgeries shouldn’t be difficult like today and yesterday. We have two hysterectomies that are straight forward situations and also a possible tuboplasty. We also have a laparotomy for an ovarian cyst, I believe. Four cases will be enough. We should be done by late afternoon.
Thank You, Lord, for a good day. You were here with us and guided us through all these surgeries. Especially, Lord, You gave the gift of salvation to the one lady who was 80 years old. She received the most precious treasure ever today. Thank You for allowing us to be here with her when she gave her heart to You. Lord, I pray for our patients. Please comfort them and help them. Please protect them from any complications and problems. Please instill Your healing power to allow them to recover quickly. Lord, we depend so much on You in everything. Thank You for Your unfailing love. Amen.
Medical Missions 
I, too, can’t comprehend throwing children away, but in my work with prisoners here in America, I have discovered quite a few situations where families have done similar things. It doesn’t seem quite as obvious, perhaps becase our overall physical conditions are better in the U.S., but nonetheles, parents neglect children, deprive them of food to feed their own habits, introduce them to destructive lifestyles, and selfishly explot them in a variety of ways. It’s a sin problem, and it comes from the Evil One. What a blessing when someone like Damary’s mother intervenes and redeems a life!