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2/11/08 (Monday)

Our surgery week begins.  We are planning on going to the OR about 7:00 to get everything ready and possibly start the first case by 7:30 to 8:00.  After the first surgery we will then stop to eat some breakfast.  We have five surgeries today, a couple I anticipate will take at least 2 hours apiece and the others could range from an hour to two.  It will be interesting to see how our team works together and how much time we can save through the day with the efficiency the team brings.  The two recovery room nurses, Annette and Linda, will be very helpful in preparing the patient for surgery as well as monitoring the patient immediately post-op and in the albergue.  This will take the load off the surgeon and anesthesiologist so we can move ahead with the next case.  In the past we stopped any forward progress until the patient was moved to the albergue because the only people who could monitor the patient were the surgeon and the anesthesiologist.  Having trained and experienced nurses to assist here will be a huge help.  Also, having a third surgeon along will support the nurses and will give us all a break from standing in one position all day.  Linzy will be a big help as well working as a scrub tech.  She will teach Angelita and Maria Luisa on instrument set up and how to organize and pass instruments.  By having Linzy scrubbing a lot, Angelita and Maria Luisa will have the opportunity to keep up with the laundry and instruments so the day won’t be so long for them as well.

Father, our surgery starts today.  This is what we are here for.  This is how we can serve You by offering this level of care to these people.  Lord, this is how we can be Your instruments to share Your love with these people.  Please, Lord, wrap Your hands around our hands and guide us.  Fit us like a glove would fit, Lord.  Make Your presence known every minute of the day.  Give us wisdom to make the right decisions and do the right procedures.  Give us the skill we need to perform those procedures.  Strengthen us and provide for us the stamina we need to hang in there throughout the day.  Lord, I ask so much and I know You are listening and will provide just what we need.  Father, this is what walking with You is all about…leaning on You, drawing from You all what I need every step of the way.  You are the guide here.  You are the one who is determining the direction we will walk.  I get the sheer privilege to walking next to You the entire trip.  Lord, I many times don’t think as much about this privilege as I should.  Yet, You patiently and lovingly put up with me and include me in Your plans.  Father, may Your will be expressed through us today.  This is a work of absolute praise to You.  May it be so and not be distorted or blocked by anything that would distract us.  Protect us and our patients today.  Thank You, Lord.  Thank You.  Amen.  

7:45 PM.  We are finished with our day in the operating room.  We had five surgeries.  We started early and it was dark by the time we returned to our sleeping quarters.  The walk from the clinic building to the sleeping quarters was in the rain.  It is raining steadily at this time.  Jane says when it rains here it is usually straight down with little wind and occasional lightning and thunder.  She says that the strong thunderstorms with sideways rain, lots of wind, lightning, and thunder that we experience frequently in Indiana are unheard of here.  It is the rainy season here we will likely experience rain frequently, usually after dark.  If tonight is like previous times, it will rain most of the night and then the sun will be out tomorrow bringing lots of heat to the already high humidity.  My back is a little sore from standing all day and my legs are stiff.  The ankles are a little sore.  This year I brought my Crocs footwear and they are very comfortable.  Standing all day in these shoes is nothing like I experienced last year when I was wearing walking shoes.  I am glad I brought these shoes.   

Our first surgery was a vaginal hysterectomy and anterior/posterior repair.  This woman had uterine prolapse with her bladder and rectum protruding as well.  Barb scrubbed with me and we were able to complete this surgery without much difficulty.  One problem Jane has is an operating room table that does not have good stirrups.  The stirrups she has to elevate the legs are largely in the way to comfortable perform vaginal surgery.  It is a challenge to get the surgery accomplished.  It is not that the conditions are unsafe, just awkward at times.  Our surgery went very well and we got a good result. 

Our second surgery was a 40-year-old woman who has never been pregnant and desperately wants to conceive.  She had multiple fibroids of her uterus causing the uterus be the size of a 4-month pregnancy.  She wanted the fibroids removed to improve her chances of pregnancy but not lose her uterus.  Sometimes so much damage and distortion of the uterus occurs with this surgery that the chances of pregnancy are not good and if pregnancy occurs the risk might be much higher for uterine rupture.  We told her we would do what we could to save the uterus.  Upon entry into the abdomen, we found several large fibroids that involved the full thickness of her uterine wall.  Unfortunately, we entered the endometrial cavity removing one of the fibroids that was involving her lower uterine area.  We removed several fibroids from inside the cavity as well as several from the wall of the uterus.  We did not remove them all because doing so would have totally ruined the uterus.  In fact, we stopped in the middle of the procedure and talked with her more about just doing a hysterectomy.  The safest procedure for her would be hysterectomy; but that means losing her fertility.  She did not want a hysterectomy at this time.  The surgery was difficult and I do not know how well her uterus will function once it heals.  She certainly will need a C-section for her delivery.  These types of cases are difficult for me because we result in less than optimal results and may have even increased her risk of a disaster if she does conceive.   

Our third surgery was an older woman who had a prolapse of her bladder and rectum.  She underwent an anterior repair to fix the bladder relaxation and a posterior repair to strengthen the support of the rectum.  Her surgery went quite well.  While we were in the middle of this surgery Annette and Linda came in to tell us our myomectomy patient was bleeding moderately vaginally.  We suspected this might happen from the work we did inside the endometrial cavity.  Our thoughts were we might likely need to bring her back to the operating room if she kept bleeding.  Fortunately, as time went on, the bleeding slowed dramatically and she stabilized.   

Our fourth case was a woman who presented with a large cystocoele and stress incontinence.  Her exam was a little different compared to the previous women who had vaginal repairs.  Because of her situation, I felt her best treatment would be an abdominal approach.  Thus, we did an abdominal hysterectomy and then a Burch urethropexy that corrected her cystocoele very well and should give her good bladder control.  As with all the patients today, this woman received a spinal anesthetic.  During the surgery, she became nauseated and then vomited several times.  The anesthesiologist showed us the emesis basin and in her vomit was a 6 inch round worm, an intestinal worm called Ascaris.  I have never seen this in a vomit before.  Jane said this is a very common problem in Ecuador, especially in the rural areas because of poor water quality.  She said she frequently sees the roundworms in patient’s stools or vomit.  Jane has medication that will kill the Ascaris and this woman will receive that tomorrow.   

Our fifth surgery was a woman with a bladder prolapse and stress incontinence.  Barb did the anterior repair as I assisted her.  This surgery went very well.  

By the time we were done with our surgery schedule, the sun was down.  We were not able to get outside at all today.  Now it is raining and the sound of the gentle rain on the roof and on the leaves of the sugar cane growing outside my room will put me right to sleep tonight.  Before that, however, is our dinner and that will be ready soon. 

We just finished dinner at 9:00 PM.  In Ecuador the evening meal is rather light with lunch being the largest meal of the day.  Dinner was tuna salad over rice.  It was quite good.  The tuna salad has hard boiled eggs, onions, and lime juice along with the tuna.  It has a different flavor and is delicious. 

Our pumps for water have failed and we are having difficulty getting running water.  We can shower if we wish but water will be limited.  I hope that this problem can be resolved because we need water for the clinic, especially for surgery.  Our day tomorrow will be much like today, 5 surgeries and probably on our feet from 7 AM to 7 PM or later.  Our post-op patients are doing well at this time and we will soon be heading to bed.  It will feel good to lay down and rest. 

Father, thank You for a good day.  Your presence was definitely felt as we performed the surgeries and cared for these women.  Thank You for helping us with the difficult myomectomy surgery and giving us the wisdom to know what to do.  Lord, thank You for providing stamina and energy to accomplish all we did today.  Thank You for watching over Linda and Annette as they spent their day in the hot and humid room caring for the post-op patients.  Thank You for Linzy as she spent the day as our scrub nurse and for Barb who was a great help in surgery.  Lord, please give us all a good rest tonight and help us restore the pumps so we can have water.  Thank You, Lord, for Your incredible grace and mercy.  Thank You for allowing us to experience and enjoy Your unfailing love.  We give You all the praise!  Amen.


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