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9/24/06 (Sunday)

Sunday, September 24, 2006 

6:20 AM.  I awoke at 5 thinking about our Maryuri, our lady with the myomectomy and the question of internal bleeding.  I slept good till then but then my mind was reviewing her surgery and her post-op course and I could not get away from the decision to take her back to surgery to explore the abdomen and determine if hysterectomy is necessary.  If she is bleeding from the uterine incisions and they can’t be controlled, we would have to do a hysterectomy to correct the problem.  She had told us at the front end of her surgery that she really wanted to save the uterus but if hysterectomy was needed she would accept that.  What we found at surgery was the opportunity to remove the fibroids and not disrupt the uterus, thereby saving it for her.  Now she has evidence of bleeding internally.  I tossed and turned and prayed fervently for Maryuri.  We need to decide today what course we are taking.  Then if we decide about hysterectomy, we have to deal with anesthesia.  This will stretch Jane and I beyond our limit, I feel.  However, with God all things are possible.   

Lord, as I mentioned before I write this down, I need You so badly right now.  Maryuri presents with a problem that could threaten her life.  We have exhausted our surgical supplies but we could put something together to do another surgery if needed.  We have no anesthesiologist available so if surgery is needed we would have to provide that ourselves.  Another surgery for Marjory will place her at higher risk for complications yet it could turn around the process and help her as well.  Lord, I am uncomfortable just sitting and observing but also am uncomfortable at the prospect of taking her back to the OR.  What should we do, Lord?  We need Your insight and Your infinite wisdom right here, right now.  Lord, we need Your healing power and Your all-sufficient grace to surround us and envelope us.  We need Your clarity, Lord, to know what we should do at this time.  Lord, as we prepare to see her this morning, please guide us and make it clear what we should do for Maryuri.  Lord, I pray for Jane and me as we make the decision on her this morning.  Lord, I especially pray for Maryuri.  Please keep her safe.  Please, Lord, heal her and hold her close to You.  I rest in the comfort of knowing You are with us and have been throughout all this week.  You have provided in so many ways, Lord, and we are overwhelmed with awe as we think back over the past week and see Your work and Your provisions and Your miraculous healing power.  Lord, we are placing ourselves in Your hands and want to do only what You want us to do.  Please protect us from the distractions that would exile us from you.  Please take the worry away and allow us to think clearly and act according to Your will in this.  Lord, I pray all this in Your precious, holy name.  Thank You, Lord Jesus, Thank You!  Amen. 

9:15 AM.  Rounds are complete and many of our patients are going home.  Typical to our rounds was the “great cloud of witnesses” that developed as we moved from bed to bed.  Family members of patients would follow us from person to person and as we would change a dressing or remove a catheter, they would lean in and watch.  On Maryuri we drew some blood for a hemoglobin and hematocrit.  Maria Luisa came this morning having stopped at a lab to get a blood sample tube.  As Jane was drawing Maryuri’s blood, I reminded her of the Scripture where it says, “Since we are surrounded by a great cloud of witnesses, let us press on toward the prize…”  Jane laughed at the comparison as she looked behind her and saw all those attending the performance.   

Before we walked over to the albergue I told Jane how I was troubled by what was going on with Maryuri and how I was praying for clarity and a clear answer to what we should do today for her.  I told Jane my gut was telling me to re-explore her belly and if the uterus is bleeding and we can’t control it we may have to do a hysterectomy.  Jane, likewise, was worried about her.  We left the house and headed toward the albergue only to see Maryuri standing outside with her husband drinking a cup of tea.  She was standing, walking and looked great!  She is pale from blood loss but obviously not symptomatic.  We almost high-fived each other right there.  We decided to see all the other patients first and then see Maryuri so we could draw blood and I could do a vaginal exam.   

All the other patients were doing very well.  Most will go home today.  One lady preferred to stay another day because she likes it here.  She brought her own mattress, a thick twin-size, for the bed.  Jane said that was common where the families would bring not only their bedding but their bed as well.  The mattresses in the albergue are thin, only about 2 inches thick, and hardly give any comfort at all.  They lay on bed boards with spaces between the boards.  I am sure they are uncomfortable.  I would love to see this place equipped with better, more comfortable beds for the patients. 

Corina, an older woman, who had a right inguinal hernia and umbilical hernia repair as well as a vaginal hysterectomy and anterior/posterior repair, was having difficulty getting up.  Her surgery went very well with very little bleeding.  I did my part while Jane did the hernias and I finished before she did.  The surgery was fast and we hardly used any sponges because of the lack of bleeding.  Yesterday, she complained of being dizzy when upright.  As long as she would lie flat she felt fine.  Sitting up resulted in dizziness.  She had no headache but her symptoms made me think it had something to do with the spinal anesthetic.  Her blood pressure was great and pulse strong and slow.  This morning she still complained of the dizziness when up.  Jane took out her catheter and said we will try getting up today and she could probably go home today.  The lady said she wanted to go home.  While we were drawing blood on Maryuri the family of the older lady tried to get her up to go to the bathroom.  The lady promptly passed out and we had to rush to the bedside to assist in getting her back in bed.  The family tried to deal with it quietly but Jane saw what was happening and told me as I had my back to the action.  Once the lady laid back down she promptly awakened and her vital signs were totally normal.  We are trying to figure out the dizziness.  The fact that the family seemed to take it in stride made us think that they may be used to this action.  We checked her over again and saw nothing that would suggest bleeding or a problem that would cause the fainting.  So we will watch her today and likely send her home tomorrow.   

Another lady on whom we removed an ovary is a Chachi Indian from the rivers.  She and her husband don’t speak much Spanish and her husband just sits at her bedside and stares ahead.  He doesn’t seem to do anything but sit.  He sits there all day and never says a word to anyone.  I would be so bored and fidgety that I would not be able to do that.  The lady was lying in the same position this morning as she was last night.  She hadn’t moved at all.  Jane made her sit up and tried to convince her that she needed to move around.  She said if she didn’t do that the lady would lay there in that position all day.  These people from the rivers seem so “foreign” to the people here in San Lorenzo.  They don’t interact and seem totally out of their element.  I would bet they are really out of touch when and if they ever went to the big city like Quito.

Jane and I talked about what we will do with Maryuri.  I did a vaginal exam on her and found the uterus like I would expect after the myomectomies.  It was not overly enlarged, tense or tender.  I wanted to make sure she was not bleeding into the uterine wall.  The exam was basically okay.  Her belly was tender and that could be from some free blood in there.  She had active bowel sounds and was passing gas.  Clinically she looked good except for being pale.  We will see what her blood count is and plan to repeat it later today.  If she remains stable, we sit.  I feel God already answered our prayers!

While we were leaving the albergue one of our patients, Bertha Baez, wanted to tell us goodbye and thank us for doing her surgery.  She is 78 years old.  Jane was giving her post-op instructions and she asked me how long Bertha should wait before having intercourse.  We had done a vaginal hysterectomy and anterior/posterior repair.  I said she should wait 12 weeks before having sex.  Jane translated that to Spanish.  Bertha nodded her head and then said, “The day after 12 weeks, watch out!!!”  Bertha, her daughter, and all the other ladies in the albergue broke out in laughter.  Bertha then grabbed my hand and told me how much she appreciated what I did for her.  Her daughter told her that she should not get too fresh with me because I have a wife back home.  Bertha then commented that I could have a wife back home but she could be my wife here in Ecuador!  Jane told me I was being propositioned and it was a good thing I didn’t understand the Spanish and I didn’t say “Si” without knowing what I was saying yes to.  

10:15 AM.  Maryuri’s family brought over the lab results that they just obtained.  Her hemoglobin was 10.6.  This was higher than what Jane and I figured it would be.  Jane asked me what my guess would be.  I said I felt the hemoglobin would be 7.8.  Jane said she was thinking 7.4.  The 10.6 surprised us.  Maryuri looks almost too pale to have that good of a count.  Now we are wondering if we should get the second count this afternoon.  If she looks stable and her pulse slows, we will continue to observe.  If we get the count and she still looks good but the count comes back at 8, then what do we do?  We also are still wondering about the sponge count.  We explored the belly and didn’t find any sponge but that problem still lurks in the background and keeps making us wonder if we should have gone ahead yesterday and explored her belly once again.  Every step of progress seems to bring more questions than answers.  

Lord, please continue to protect Maryuri and guide us as we try to help her and to the right thing for her.  We are so dependent on You for this.  Thank You, Lord, for Your presence and unfailing love! 

5:00 PM.  As the day progressed, Corina did not seem to get better.  Every time she would raise her head up off the pillow she would get very dizzy.  Jane called Paul about this to see if the spinal might have had some effect.  As we talked about her we said she appeared to have vertigo, the problem one gets when the inner ear has been affected and changing positions causes extreme dizziness and even nausea.  This is also called Minears Disease.  It usually comes from a virus infecting the inner ear where our balance system functions.  The typical presentation is the person is just fine laying flat but once the head comes up the dizziness starts immediately.  As we talked about the vertigo we looked up the drugs for that.  The main drug used in the States for vertigo was Antivert or meclizine.  The meclizine seemed to ring a big bell in my head as something very familiar to me.  We looked up meclizine and saw it is also used for motion sickness.  I checked my Dramamine tablets and found that this is meclizine.  So I took some of these tablets and gave them to the patient.  She has one dose down and we just sat her up and she was able to tolerate sitting for a couple minutes before the dizziness started.  At least this was not immediate as before.  We will continue the meclizine through the night and then write a prescription for more so the family can purchase this for her.  She may need to stay on this for several days before the vertigo is controlled.  Why she suddenly has this problem now is a mystery.  The spinal anesthetic would not cause this.  The surgery probably would not cause it either.  Hopefully, we will be able to send her home tomorrow morning.   

The albergue is very hot.  The roof is low and there is not good ventilation making the room very warm and uncomfortable.  I don’t know how the patients can tolerate the heat.  They must be used to it because they are all lying under some sheets and keep themselves covered most of the time.  Jane and I talked about getting some ventilation in this building.  She has a work crew coming from the Island of Jersey near England to help construct the OR building project.  She said they will all be staying in the albergue.  I suggested that a couple of the workers could enlarge the windows and even put some ventilation ports in the wall just under the roof to allow the air to circulate up and out of the room.  That might help lower the temperature some.  Jane also said she would like to get 8 wall mount fans and put 4 in each room in the albergue to keep the air moving and the patients more comfortable. 

I have been getting all my things packed and ready to travel in the morning.  I did a couple loads of laundry and now have all clean clothes.  That way when the customs officials open the suitcase they don’t die from the smell.  Tomorrow we will likely head out of here in the morning and stop at Otavalo on the way to do a little shopping.  We will then move on to Quito and get established there.  Tuesday we will take a little side trip to the Nunnery’s to talk with them and review the ultrasound for Barbara and also watch some hummingbirds.  I would like to get some good pictures.  Wednesday I fly back home. 

8:30 PM.  Jane and I took another look at the patients in the albergue.  Corina had not urinated all day.  The daughter stated she was drinking some.  Corina said she was not feeling any urge to urinate.  Her pulse was running about 120 and her blood pressure was 100/60.  Her usual pressure was 160/90.  We put in a catheter and got out maybe 100 cc of urine.  Jane then said her problem could be from dehydration.  We opened up her IVs and told her and the daughter to push fluids by mouth.  It is likely her dizziness is because she is volume depleted and just needs fluids.   

All the other patients are doing very well.  The Chachi Indian just sits there and says nothing.  Her husband did tell Jane that they might want to stay another day before heading back to their village on the river.  He just sits around and does nothing all day, no reading, no talking…nothing.  I told Jane I would be bored to tears if I were him.  I said I would want something to read.  Jane said he probably can’t read.  The way everyone looks we will likely send all of them home tomorrow except for the Indian who wants to stay another day in the Ritz.   

10:30 PM.  Jane and I had a grilled cheese sandwich and some Mora ice cream and popcorn.  Healthy meal, at least the grilled cheese.  It is getting close to time to call it a day.   

Lord, I want to thank You for this incredible week here in San Lorenzo.  We helped so many people and watched You perform miracle after miracle.  This was incredible.  Thank You for encouraging us and providing for us every step of the way.  Thank You for allowing us to serve You and for keeping us from being exiled from You by the details and frustrations of the moment.  Thank You for Your protective arms around all of us, the patients, the team and Jane and me.  Lord, Thank You so much!!  Amen. 

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