10/16/08 (Thursday)
5:45 AM. I awoke about an hour ago and then got up about 5. I awoke for certain when I took my shower. I don’t think I will ever get used to the cold shower. That inhale-tiptoe reflex is still functional. In a little while I will meet Jane to make rounds on the patients. We should have some more go home today. A couple ladies need their catheters removed and if they have good bladder function, they will head home. I certainly hope and pray the surgeries from yesterday do well. The 80-year-old lady has the potential of pulmonary complications post-op and I hope the vaginal approach will not induce any problems for her. Keeping an incision off the abdominal wall will allow better function with ambulation and breathing and hopefully avoid any lung problems, such as pneumonia from not ventilating well. The night was quiet except for one chorus of dogs discussing politics for awhile. The conversation became an argument that had some heat in it but soon everyone agreed to disagree and be on their way. This morning about 5 the birds started chirping and the roosters were crowing. I don’t even need to set my alarm. God provides plenty of wake up assistance.
Father, Thank You for another day. Today looks to be a little easier as far as the surgery schedule goes. Thank You for that. Father, I pray for the patients from yesterday. Please hold them close to You and comfort them. Allow the healing process to work so these ladies can be restored to good health and better function. Lord, please be with the older lady who underwent a big surgery and also became a child of Yours. She was seeking You, Lord. You prepared her heart for that moment and allowed me to witness it. Thank You, Lord, for Your unfailing love. It never ends and there is no limit to it. Thank You for what You teach me in being an agent of that love. Your love knows no boundaries. You love those who don’t love You. You offer Your gift of salvation to anyone. Lord, Thank You for giving that gift to me and allowing me the opportunity to tell others about it and encourage them to receive the gift as well. Father, that is the most important decision one can ever make. That decision determines where one spends eternity. Thank You for allowing me to understand that. I pray I can carry that message to others so they also can understand and accept the gift. Lord, Thank You for the opportunity to come here to San Lorenzo and to work with Jane and her team. She is doing wonderful work here in Your name. Not only is she able to participate in the healing process, she also is able to participate in spiritual healing. I wonder how many people have become Your children because of Jane and her team. Thank You for them and please bless them today. Lord, I depend so much on You. At times I don’t do a good job of acknowledging that dependency and don’t take the opportunity to thank You for that. Lord, please forgive me. Without You, I am nothing. Thank You, Lord, for loving me the way You do and for providing incredible mercy and grace when I don’t deserve it at all. Thank You, Lord, for the hope that fills my heart because of You. Thank You, Lord, for the joy I experience walking with You. Thank You, Lord!! Amen.
7:45 AM. We had breakfast that was very Hoosier, at least it is a type of breakfast I see everywhere in Indiana and across the USA…pancakes and syrup. The pancakes were delicious but I really think it is the syrup that makes pancakes taste good. Pancakes by themselves don’t have a lot of flavor. I know, I’ve tried them that way. I remember when our children were young and we went camping a lot for our family vacations. I would fix pancakes and my kids thought I was the best cook in the world. They kept telling me how good the pancakes were. However, I remain convinced that it was the syrup, not anything I did. Aunt Jemima was the one to get the credit for my pancakes.
We are ready to start our day of surgery. Our first patient will receive general anesthesia. She has a seizure disorder that has not been managed effectively. She currently is not taking any anti-seizure medications. She has a history of having a hysterectomy 17 years ago, when she was age 20, and has not had any bleeding since. On a recent exam Jane found a cervix and then obtained an ultrasound that showed large ovarian cyst. When we examined her in the clinic we found she had an intact uterus and a large complex cystic mass in her pelvis. We weren’t certain as to what was done at the time of the “hysterectomy.” If the uterus is still intact, she must have had her ovaries removed. However, this cystic mass most likely is coming from an ovary. We aren’t certain as to what we may encounter once we enter the abdomen. Because of her seizures, Vivianna is giving her a general anesthetic so the seizure component will not complicate our surgery. We will also monitor her most of the day in the recovery room. At surgery we found a complex ovarian cyst buried under peritoneum on the left pelvic side wall. The ureter was close and required some careful dissection to avoid entrapping the ureter into the clamps or suture. We were able to remove the ovary once all the adhesions were cut and the ureter and vessels were kept out of the way. The right ovary was absent. A cervical stump remained from her previous hysterectomy. What was done before was a supracervical hysterectomy and removal of the right ovary. The cervical stump came out after more careful dissection since it, too, was buried under peritoneum and bladder. Once the cervical stump was removed we were able to revisit the ureter and make sure it was okay. Then we finished the surgery. We will watch this patient in recovery all day because of her seizure potential.
Our second patient is 30 and has had problems with pelvic pain, especially with menses. On exam she has multiple fibroids and palpation of the uterus is quite painful. This reproduces the pain she experiences. Her ovaries were normal size but both were tender with the left side more tender than the right. Our working diagnosis is pelvic pain related to the multiple uterine fibroids. She could also have endometriosis. Interestingly, I have not seen any endometriosis on any of my trips here. In the US this problem is quite common and is a source of menstrually-related pain. At surgery we found evidence of old infection with multiple filmy adhesions around both ovaries and over the uterus. Once these were cleaned up we then isolated the ovaries and kept them intact. We removed the uterus and tubes leaving the pelvis clean of adhesions and both ovaries with good blood supply. This should really help her pain.
When this lady was taken to the recovery room, Maria Luisa went in and talked with her at length. Jane and I were working on some details in the operating room and we heard Maria Luisa begin praying the prayer of salvation. We then learned that Maria Luisa had spent time talking with this patient about where she will spend eternity and the patient accepted Christ into her heart and life. Maria Luisa is tenacious in her pursuit to share Christ with people. Each day now she has led one of our patients to the Lord. I wondered aloud to Jane about how many people Maria Luisa has introduced to Jesus Christ. Jane said she couldn’t count that high. She said when we get to heaven Maria Luisa will be a queen and she will be her servant.
2:00 PM. We stopped for lunch. Today, Loita prepared ceviche, a very delicious combination of shrimp, chopped onions, lemon juice in a tomato sauce. This is all cold and is served over hot rice. The taste is unique and absolutely delicious. Jane introduced me to ceviche on a previous trip and I must say it is one of my favorite Ecuadorian foods. I even got the recipe on a previous trip and tried making it at home but it was a classic failure. I tried to impress Phyllis with this dish only to have it be a very poor representation of what is truly an adventure for the taste buds. Now that the meal is over, we must move on to our afternoon surgeries.
Our third patient is 34 and had a tubal ligation thirteen years ago. She wants to conceive again and really wants a tubal reversal procedure. She has had 2 pregnancies after her tubal ligation and both of these ended in first trimester miscarriage. She has had pelvic pain and uterine fibroids in the past. A recent ultrasound in September 2008 was read as normal. Our option is to look with a minilaparotomy and then proceed with a tubal reanastamosis if it appears feasible. She understands the tubal reversal procedure may not be possible. At laparotomy we found both tubes to have a single ligature around them without the tube appearing to have been interrupted. We were able to excise the small portion of tube where the ligature was and then rejoined the tube. This was done on both sides. This should give her functional tubes and she should be able to conceive. Her risk for tubal pregnancy is higher. She had no evidence of any tubal disease such as adhesions or evidence of infection.
Our fourth patient is 22 and has never been pregnant. She has a history of a right ovarian cyst and long menses, sometimes bleeding for 30 days. At the time of her menses she has pelvic pain. On exam I could not feel a cyst or mass on either side. An ultrasound shows a right ovarian cyst. Our plan is to look with a minilaparotomy and remove the cyst. Once we looked in the abdomen, the problem became clear. The cystic mass was a large inflammatory cyst that involved the right tube. The right tube was clubbed and closed. The left tube likewise was scarred closed and an inflammatory cyst was forming there as well. There were multiple adhesions in the pelvis. All of this was a result of some pelvic infection as some time in the past. The likelihood of this lady ever being able to conceive is very low if at all. Damarys scrubbed with us and she told me as we were closing that in this culture a woman who cannot conceive is considered not useful to her husband. She becomes an outcast and spends her life agonizing over her barrenness. The probability is good that the initial infection was given to her by some man. Now her reproductive abilities are destroyed. And, to any man it will be considered all her fault and her usefulness is gone. I asked Damarys if adoption was available in Ecuador. She said sometimes adoption occurs but only in the big city. Here in San Lorenzo adoption would not even be considered. This was a sad situation. It is difficult to avoid getting caught up in the emotions of this problem. Your heart goes out to this lady because of the life she faces from this point forward.
As we were finishing a family brought in a lady on whom I had operated in 2004 when I came for the first time. She is now 80 years old and has something falling out of the vagina. Review of her chart showed I had operated on her for vaginal prolapse. Then we did an anterior repair, posterior repair and sacrospinous fixation to keep the vaginal inside in its normal position. When she came in to our pre-op area so we could check her, she had to be led by the hand because she has cataracts so bad that her eyes are gray-white. She is essentially blind. She was very frail as well. When I examined her the vagina was hanging out and my nonabsorbable suture from the sacrospinous fixation was partially protruding from the vaginal mucosa. She also had a significant rectal prolapse with about 5 inches of everted rectum hanging out of the anus. Jane and I talked at length with the family telling them what the two problems were and how we didn’t feel this lady would even tolerate the surgery let alone the difficult recovery time. It was a difficult conversation when they bring their mother in to receive help and we just cannot safely give what they want. We had to send her back home to be cared for as best as they could with no further plans. In my career I have never seen a rectal prolapse. However, since I have been coming to Ecuador, I have seen two patients with this problem. One we fixed in 2004 and that lady was 80 years of age and was much more robust with a higher level of function than this lady is.
While we were evaluating this lady with the vaginal and rectal prolapse, Maria Luisa came in and knelt by her and prayed for her. She then talked with her and presented the Gospel and the lady accepted Christ into her heart. Maria Luisa then prayed with her again and this lady prayed out loud for Jesus to forgive her sins and to accept her into His kingdom. It was a special moment for all of us. Maria Luisa hugged her and prayed again for her. I am so impressed with Maria Luisa’s passion to share the Gospel and to introduce people to Jesus Christ. I feel ashamed that I have not been this aggressive for my Lord and Savior.
Our day is done and it is 7:30 PM. Jane is taking the team to their homes and then we will have dinner. My legs are swollen from standing all day. My back spasm has improved some and I am glad for that. Tomorrow, Damarys, Loita and Esther will take Jane’s car to return to Quito and Dr. Nelson also leaves to return to Shell. When we are ready to leave on Monday, Damarys will probably return to San Lorenzo on Sunday so we can leave on Monday. It is amazing to me that the week of surgery is almost over. We have had some challenging surgeries and I feel we have been able to help many people. Plus, in the past 4 days we have seen 5 people come to know Jesus as their Lord and Savior. That makes this trip and the work we do here all the more special.
Tomorrow, we have a series of small cases. A couple of the gyn cases we had seen last week decided to cancel the surgery. Jane had a waiting list of kids with hernias so we will be doing hernia repairs tomorrow. I believe we have 8 surgeries with hernia repairs, a circumcision, a breast biopsy and a marsupialization of a Bartholin cyst.
Father, today heaven rejoices for two more people are now Your children having given their heart to You. Lord, You paid the price for our sins and all we have to do is accept that payment as a free gift. Salvation is so precious, far more precious than all the gold, silver, and any other precious thing this world could offer. Yet, so many people scoff at this or at least don’t want to deal with this decision today. Lord, You drew these two people to You today. You prepared their hearts so the message fell on fertile soil, took root and grew. Thank You, Lord for this great day. You guided us in the operating room, You gave us the wisdom we needed to do what was needed, You comforted us when we were tired, You gave us food that nourished us, and You allowed us to watch You work in saving two souls for eternity. What a privilege, Lord! Thank You! Lord, I pray for the people we operated on this week and today. Please bring healing to their bodies and comfort them. Thank You, Lord, for how much You love them and us. I pray for my family tonight. Please allow them to sense Your presence and to feel Your unfailing love. Thank You for them, Lord. They are so special to me. I love them so. Please allow me a restful night tonight, Lord. I thank You for this incredible opportunity to serve You here in San Lorenzo. Thank You, Lord. Amen.
Medical Missions 
May God bless each of those you have served. You and your team have been given special gifts!
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