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9/15/06 (Friday)

Friday, September 15, 2006 6:00 AM.  I awakened having had some interrupted sleep through the night because of the mosquito netting not staying tucked in.  The mattress is a little shorter than an average twin bed and my feet hang over the end.  I get tangled in the mosquito net and it pulls out.  Then I get to itching because of some new bites.  This was frustrating as I kept waking up because of bites and then spent time trying to tuck in the netting again.  I finally got up and showered and got ready for the day.  Then I spent some time working on some email. 

Our day today was seeing patients in the clinic.  Most were coming to be considered for surgery.  We saw about 30 people today and scheduled several with our next week now fairly full.  We are trying to limit our major cases to 5 per day so we can finish by nightfall.  This will also allow us to add on in case someone comes in needing attention. 

We did have a couple interesting and tragic problems.  One was a little 2 month-old baby brought in by the mother.  The baby was considered a girl but has ambiguous genitalia.  Jane asked me to look at this to see if there was a vagina or evidence of the female gender.  What this little baby had was male genitalia that were not fully formed but mostly.  I felt this baby was male and not female.  The best way to determine gender would be to get a blood test and check the chromosomes.  However, that is a cost that the family could not bear, so that option is out of the question.  Jane talked with the mother and explained that the child was likely a boy.  The mother shrugged her shoulders and said, “Then I’ll just change the name.”  To her it was not big deal.  She already had the baby’s ears pierced and Jane reminded her to take out the ear rings.  I did take some pictures to email to my urologist friend, Rhys Rudolph, in Fort Wayne for his opinion. 

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The genitalia were not truly female and not truly male, although the male characteristics were more prevalent.  There was one gonad in the right testicle area that could have been a testicle or an ovary or a mix of the two called an ovotestis.  The left side was empty.  These problems can lead to cancer of the gonad at a young age.  Plus it is important to determine the gender to the child is reared accordingly.  This child needs a work-up with blood tests and other exams.  I wonder if that will happen because that will cost money that the family does not have.

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Incomplete formation of the penis and scrotum.

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A tragic situation involved a lady who Jane had met a couple weeks ago.  She lives in a house close to the clinic, just behind the clinic property.  Jane had actually tied her tubes a few years ago.  Recently, Jane had been told this lady had gone to Ibarra because of sudden, heavy vaginal bleeding.  There she was evaluated with an ultrasound and was given 3 units of blood.  She was sent back to San Lorenzo still bleeding with no further treatment.  She did receive an injection of some hormones at Ibarra.  Jane saw her a week or so ago and at that time the bleeding had stopped and she was doing okay.  However, Jane was uneasy with the whole situation and the fact that this bleeding occurred in the first place kept bugging Jane.  Jane had mentioned to me via email before coming here that she wanted to bring this lady in for me to examine because she had this nagging feeling that something wasn’t right.  Consequently, we had that opportunity to see her today.  She came in with an ultrasound that was read as normal and was not bleeding.  When I went to examine her, I found a large, fungating cervical cancer.  This cancer was involving the cervix only and on exam I felt it was still a Stage 1 and was resectable.  Jane then told her what we found and that she had cancer.  The lady about collapsed on us.  She began to cry and cry and put her head in Jane’s lap and just cried in despair.  After some consolation, Jane offered to pray with her.  At this we all joined hands and prayed earnestly for several minutes.  We scheduled her for this next week to remove the uterus and cervix and at least get rid of the source of bleeding.  We may not cure her of the cancer but we can at least keep her from bleeding to death from a hemorrhage that won’t stop.  I felt so bad for her because she is so poor and cannot afford any type of care.  Here in Ecuador, if someone has no money, there is no medical care.  You get sent home to deal with the problem or die even with no apparent compassion or empathy on the part of the health care providers.  These situations are so tough.  This lady is the third invasive cervical cancer we will operate on this week.  Each will receive a modification of a radical hysterectomy.  Each has fungating tumors on the cervix and have been bleeding but not nearly as bad as this lady today.  Cervical cancer is the #1 cancer in women in Ecuador.  In the States cervical cancer, especially the invasive type, is relatively rare anymore.  It has been years since I saw invasive cervical disease in my practice.  We screen the women regularly in the States.  Here, a woman may go her entire lifetime without ever having a pap smear.   

We finished the clinic about 6 PM after spending the day in a very warm and humid exam room.  I took my thermometer over to the clinic and the peak of the day the temperature reached 89 degrees and the humidity 85%.  That combination creates a lot of sweating just sitting.  I wish Jane could do something to the building to provide better ventilation or even air conditioning.  Jane tells me this is being looked at with the new construction being planned to add on to the building to develop a better OR and pre-op and recovery room.   

The motorist and a couple of the people who worked with Raquel came to San Lorenzo to pick up some medications Jane had for Raquel.  While they were with us for a few minutes I happened to have my computer up and running so I showed them the Google Earth images on the full screen.  The motorist immediately recognized the river and was fascinated with the images of his world as seen from high in the sky. 

We had a light meal of a cold meat sandwich and some popcorn and spent the evening working on email.  Jane signed on about 9 PM with her computer and found an email from the anesthesiologist who is to come and work with us next week.  The email was brief and to the point…he wasn’t coming because he was ill.  Jane immediately called Damarys and talked with her about this.  We have about 25 surgeries scheduled and now no anesthesiologist.  We have more people to see tomorrow.  Damarys made some phone calls and then called back to tell Jane that the anesthesiologist came down with toxoplasmosis and was told he should not work for at least a week.  That is understandable; however, it leaves us in trouble.  Damarys talked with Paul who has worked with us before.  Paul originally could not come because he is pursuing some degree work and is in class.  He then considered the possibility of coming on Tuesday through Friday.  Jane and I talked about the difficult surgery schedule that would give us if we put all the cases on those specific days.  It is doable but would be very long days.  We have three patients with cervical cancer and we really hate to cancel these cases.  Other elective surgeries could be rescheduled for a later time.  This is a tough predicament.  Jane finally said, “We have to just rest in God’s hands on this.  He brought us here and He is in charge.  He will provide for us.”  I agreed and we prayed specifically for God’s intervention here. 

Jane also shared with me what Angelita and Maria Louisa were talking about when Jane took them back to their homes.  A couple weeks ago two ladies, one was pregnant, were in a boat in the water heading to San Lorenzo.  A boat with a couple men pulled up beside them with the intent to rob them.  The pregnant lady recognized one of the men.  Because she knew the man, they decided to kill her.  They killed her and took a machete and cut her open and took out her abdominal organs and cut open the uterus and took the baby and threw the lady, baby and organs in the water.  The reason they took the bowel and organs out was so the body would sink and not float to the surface.  They then raped the other lady and left her alone in the boat.  She reported all this to the authorities in San Lorenzo.  She did not know who the men were. 

Lord, this place represents what happens in man’s mind when Satan takes over.  He is the father of lies and he is bent on destruction of mankind.  He also desires with all his heart to sit on Your throne.  I know You are the God of all the universe including absolute control over Satan and his demons.  As pictured in the first part of Job, Satan must bow to You and he always will.  You will never give Your place of authority and power to anyone.  Thank You for that confidence.  Even though my life may encounter temporary troubles, I rest in the assurance that You are there with me and You are in control.  Thank You, Lord, for allowing me to walk with You here in San Lorenzo.Amen.

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