9/22/06 (Friday)
6:00 AM. My internal alarm went off awakening me whether I was needing sleep or not. I awoke to the sounds of buses and trucks and roosters and dogs. The fan wasn’t running and I realized that we don’t have power. That means no shower or water to clean up and feel a little bit refreshed. Another stress for the morning! I was able to use my drinking water and clean my face a little.
Lord, I am tired and need some more rest. Yet today we have another full schedule with some challenging surgery ahead of us. We have post-op patients to see and all of this without electricity. Father, these issues can exile us from You so easily. Please keep us focused on You and on the work before us that You called us to perform. Lord, we are here to serve You and we can’t allow other distractions to get in the way of that mission. Please, Lord, encircle us with Your love and Your grace and do the same for our patients. Lord, touch them with Your healing hand, allow Your healing power to flow into their bodies and bring healing to the surgery areas. Lord, protect them from harm, especially infection and other complications that could so easily occur. And Lord, I commit this day and the work before us to You as a service and honor to You. Grant us Your grace today, for that is sufficient for all that we do. These things I pray in Jesus’ holy and precious name. Amen.
Jane told me the other day that the local people like to get any type of clothing, especially shirts, that have something written on them in English. The sport these English words like they know what they say. It is a big thing to have clothing with words in English on them. She said not too long ago a lady came into church wearing a T-shirt that had written on it, “Eat Shit and Die.” Jane said she could hardly keep from laughing in front of the lady because she knew this lady had no idea what her shirt was saying. Well, this morning a daughter of one of our patients came in while we were making rounds. She was a pretty lady about mid 20s, nice figure, etc., and was wearing a nice skirt and tank top. The tank top was a size or two too small but otherwise she looked like she was dressed to go to church or to some business. The tank top had this English statement on it, “Tell your boyfriend I said thanks.” I told Jane to read the words when she had a chance. She then casually looked around while she was talking to the lady and saw the tank top. She almost burst out laughing. She said this young lady probably has no idea what the tank top says and the message that she was sporting around. Jane has been laughing about it all morning.
Our first case was a tuboplasty to help a lady conceive. She had had a hysterosalpingogram that demonstrated blockage of the tubes at the end with what appeared to be normal tubal structure otherwise. We looked at her tubes and they appeared healthy except for the ends were closed and there was a small amount of fluid in the every end of the closed tube. I was able to open up these tubes and performed a cuff tuboplasty where the end of the tube is rolled back on itself like a cuff of a shirt. The edges are then sutured to the outside of the tube to keep the tube from closing up again. We were very pleased in being able to do this procedure and leave this lady with a much better likelihood of conceiving.
Our second case was an older lady with an umbilical hernia, right inguinal hernia and uterine prolapse. We did a double set up and Jane repaired the two hernias while I did the vaginal hysterectomy and bladder and bowel repair. I finished just before Jane did so we saved ourselves about an hour and a half by being able to work simultaneously.
Our third case presented with heavy bleeding and a large pelvic mass that seemed independent of the uterus. We thought it might be a large fibroid involving the right side of the uterus. Once we opened the abdomen however, we found a uterus that was grossly enlarged from multiple fibroids. The uterus was the size of a 20 week pregnancy. We performed a hysterectomy to manage these fibroids and the heavy bleeding.
Multiple fibroids distorting the uterus and causing it to be significantly larger than normal.
4:00 PM. Our fourth case is now ready. This has been a long day already and we have two cases to go.
Lord, this has been a better day at least with less problems to sort through. However, this next case is an enigma. We have ultrasounds that don’t agree and suggest possibly a large mass inside the uterus. The lady has never conceived and she desperately wants a pregnancy. Please be with us and empower us to treat her appropriately. Help us to make the right decisions regarding the fibroids and if possible to remove them without damaging the uterus. Thank You, Lord, for Your unfailing love. Amen
8:30 PM. Our fourth case is over. The lady, Maryuri, had a huge fibroid coming off the posterior wall of the lower uterus and cervix. She was the one who presented with the ultrasound that suggested the mass to be inside the uterus. It did not seem to involve the interior of the uterus at all. She also had a large pedunculated fibroid on the top of the uterus. We were able to remove the fibroids and not disturb the uterus significantly. One problem presented itself as we closed the abdomen. Our sponge count was incorrect. We were missing one sponge. We counted and recounted and still came up one short. Jane and I reviewed what we did with sponges in our surgery and we didn’t feel we had put one into the abdomen. However, to be sure we took out our stitches and opened the abdomen once again. The patient’s spinal was wearing off so the anesthesiologist had to give her some sedation to allow us to explore for a missing sponge. Jane and I both felt all around the abdomen and did not find a sponge. Angelita and Maria Luisa both felt they counted correctly when the put the sponges together. However, they are used to packaging towels in fours and other drapes in fours and one of them could have put four sponges into the pack instead of five. The error was when the pack was opened they did not recount them before putting them on the sterile field. We felt certain we did not leave a sponge inside the abdomen. However, this did become an important teaching lesson about the importance of having accurate sponge counts and accurate processes of checking and rechecking all the time. Angelita and Maria Luisa felt so bad about this incident. They both cried for some time. These ladies work their hearts out trying to make things run well for Jane. Jane has taught them all they know and they are so sensitive when a mistake occurs. Jane tried to encourage them but also wanted to make sure the importance of accurate counts was learned.
The series of pictures below show the uterus and the fibroids that were quite bizarre in their appearance. I told Jane I had not seen such complex fibroid cases in a long time. I suppose we intercepted these problems long before they got this big. Maryuri’s situation presented a real challenge in getting the uterus restored to normal.
There is one large fibroid on a stalk coming off the top of the uterus (to the right in the picture). The tube and ovary are coming off the upper corner of the uterus (in the center). The large mass on the left of the picture is a large fibroid in the lower portion of the uterus and involves the cervix.
I am holding the uterus at the fibroid on its stalk. In front of the uterus are more fibroids.
I am opening the uterine wall to remove the fibroid. In my other hand I have a clamp on the large fibroid I was dissecting out of its site in the uterine wall.
The fibroid is removed. It was larger than a baseball.
I am removing a smaller fibroid off the front side of the uterus. The last step was removal of the large fibroid on the stalk.
Maryuri posed with Jane and me on her day of discharge. She was so pleased that we were able to keep her uterus.
Maryuri and her husband.
Maryuri had an ultrasound performed a year or so earlier. It actually demonstrates the correct anatomy of the location of the fibroids.
Our last case was a possible tuboplasty. This lady had old pelvic infection and there were multiple adhesions all over the tubes and ovaries. The tubes appeared to be open; however, to spend several hours going through cleaning out all the adhesions likely would not give this lady any better chance of pregnancy. We talked about the outcome and decided that it would be best to not get aggressive with the adhesions. We did clean up some of the adhesions and inspected the tubes and got out. In the States this lady would have the best chances of pregnancy with in vitro fertilization. Obviously, that is not available here. It was a hard decision to sort out what would be best for this lady. I didn’t feel taking this lady through aggressive surgery would benefit her significantly. This problem is related to changes from an old infection. One can clean up the adhesions and within 48 hours they are back again. I felt it was best to do no harm to this lady and back out.
11:00 PM. I am back at the house and getting ready to go to bed. Paul and I had a bowl of soup to eat. I want to get off some email before going to bed. Surprisingly, I am not as tired right now as I thought I would be.
I did have one incident of making a fool of myself today. At the end of each case Jane would shake my hand and say, “Thank you, Doctor!” and then would shake Angelita’s hand and say, “Thank you, Nurse!” She would say this in English. One of the cases Jane broke away to take care of the paperwork while I closed the incision. Once I had the incision closed I turned to Angelita and grabbed her hand and said in Spanish, “Gracias, Enferma!” She looked at me with an odd look and I caught on that I must have said something totally wrong. Jane then laughed and said that I used the word for “sick” instead of “nurse.” I then realized that enferma in Spanish means sick and enfermera means nurse. Jane laughed and said I told Angelita, “Thank you, sicko!!” I was really embarrassed. I then corrected my Spanish and called her enfermera. She then caught on to what I was trying to say and she and Maria Luisa just howled with laughter. Jane said that they would not connect the two words as similar because they think in the meaning and wouldn’t even see the similarity. When I said the right word they then realized how I botched the Spanish and had a good laugh over my attempt to be cool.
Lord, Thank You for a good day. We had some difficult surgeries once again. This week, Lord, has been full of difficult surgeries, much more so than I remember from previous trips. Through Your power and grace we have been able to minister to several people and help them improve their lives. We have been able to pray for them and even share Your love with them. Thank You, for this opportunity. Lord, be with Maria Luisa and Angelita tonight. They are so discouraged over the sponge count problem. Please lift them up and love them in a special way right now. Lord, please also cover our patients with your healing power. Thank You for allowing Jane and I to help these people through surgery. Thank You, Lord, for bringing me here to San Lorenzo. Your name be praised! Amen.
Medical Missions 
I think that you are a great doctor that cares or all that’s why the lord sent you that way for the reason. Amen and at God bless you Sir..