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11-10-2011 (Thursday)

6:30 AM.  I am up and ready to start the day.  Another 9 hour sleep!!  In spite of the outside noise and the heat and humidity, I am sleeping like a log.  The fan provides a soft white noise and the constant breeze that keeps me cooler and blows the mosquitoes away.  Last night the mosquitoes came out in droves.  There must have been a new hatching of them in the area for they were much more abundant and hungry.  Even with screens on the windows I had several in my room.  I always sleep under a mosquito net which protects me through the night.  The net makes getting in and out of bed an experience but with sleeping so soundly I haven’t had a problem with that.  My legs and ankles are swollen from standing in one position all day and that swelling doesn’t go down completely at night.  Plus, the food Nancy prepares is fairly salty at times so I am sure my salt intake is higher. Last night for dinner we had squid over rice.  It was fairly tasty.  There was some left over and we will likely see it put out for breakfast or lunch today.

Our surgeries today involve myomectomies.   These are situations where women have fibroids that are interfering with normal uterine function and at times conception.  They want to keep the uterus and their reproductive function.  To better their chances at pregnancy and also to manage problems the fibroids are causing, a myomectomy or removal of the fibroid is sometimes done.  We had three of these patients on the schedule but the second one called today to state she has malaria and wouldn’t be coming.  Then this evening she called and said she would come in to be seen to see if the surgery could be done anyway. 

Father, thank You for the great night’s sleep once again.  A good sleep leaves me refreshed and thinking more clearly.  You have provided that for me here and I am deeply grateful.  Today, Lord, we have more surgeries.  These involve a different procedure and can be fairly difficult and complex.  Lord, help us to do the right surgery for these patients.  We want to improve their situation and not remove their ability to conceive.  Sometimes that is a fine line to walk, Lord.  Please guide us.  Thank You, Lord, for Your continual presence with us and Your unfailing love.  It is such a joy serving You, Father.  Thank You for the opportunity to come to San Lorenzo and share Your love with those we serve.  Amen.

Another discipline that one must practice regularly is prayer.  In prayer we talk with God spilling our thoughts, concerns, and requests to Him.  It is important to also confess our sins to Him and ask for forgiveness.  Probably this step should be done first to make sure there is nothing that is standing in the way of God hearing us and responding.  Then we should praise Him for who He is and what He has done for us, thanking Him for His unfailing love toward us.  We can then bring our concerns and requests to Him. 

Prayer is a time of communion with God, carrying on a conversation with Him, enjoying His presence.  It also is a time of worship when we dwell on who God is and His greatness.  We have a relationship with God; in fact, He desires it.  Some of my deepest and most treasured times in this relationship were during prayer.  I believe prayer brings us to a time like solitude where we focus on God alone and shut out the world around us.  It is during this undistracted time that I not only can lay my concerns and requests before Him but also hear His response.  If I have too much noise around me, I can’t concentrate on what God and I are talking about.  It is during prayer that the devil will do everything to interrupt this level of communication.  I find it amazing that when I am praying that the phone will ring or someone will come into the room and say something interrupting me.  Or I will suddenly have a thought hit me so clearly that it becomes the center of attention instead of me focusing on God.  Prayer becomes a discipline that must be practiced and protected from interruption.  It is a time of rich communion with God and a time when I feel closest to Him.  These moments become the catalyst to becoming more Christlike and growing as a disciple of Him.

Prayer gives me another way to know God.  I learn to know Him through the listening that takes place in solitude and also through study.  Prayer gives me time to interact with God and many times He communicates with me in this venue.  As I read in the Old Testament about a prophet named Jeremiah, I am impressed with his desire to know God.  He sought God repeatedly.  He listened to God regularly.  In his book, chapter 9, verses 23 and 24 Jeremiah writes: This is what the Lord says: “Let not the wise man boast of his wisdom or the strong man boast of his strength or the rich man boast of his riches, but let him who boasts boast about this: that he understands and knows me, that I am the Lord, who exercises kindness, justice and righteousness on earth, for in these I delight,” declares the Lord.  I look at Jeremiah and the other prophets who brought God’s Word to the people and admire these men more and more every time I read their words.  They were devoted to a lifetime of discipleship, being God’s messenger to His people.  They practiced discipleship.  They wrote the book on discipleship.  We can learn a lot about our walk with Christ by reading these books of the prophets. 

Jeremiah 29:11-13 “For I know the plans I have for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you home and a future.  Then you will call upon me and come and pray to me, and I will listen to you.  You will seek me and find me when you seek me with all your heart.”  Do you seek God with all your heart?  How can one be a disciple of Christ if you don’t seek Him with all your heart?  Seeking Him involves what we have been talking about so far this week.  We learn as much as we can about Christ through study of the Gospels and the Epistles.  We spend time listening to Him.  We walk with Him along life’s path.   And we seek Him through prayer.  All of this is driven by an all-your-heart energy and motive.  These are the steps in preparation to be His disciple, to literally practice the presence of Christ in your life every day, every minute. 

Our first surgery was difficult.  This patient is heavy and has never been pregnant.  She has a large fibroid on exam.  When we opened the abdomen the uterus was significantly enlarged because of several fibroids.  The biggest one was larger than the size of my fist, making it at least 10 cm in diameter.  Jane was able to remove the fibroid after a fair amount of dissection.  Usually the fibroids can be shelled out of their site with a finger.  There generally is minimal blood supply to them and they sit inside a capsule.  You can take a finger and sweep around the fibroid and bring it out.  This one had a lot of adhesive attachments requiring much more work to get it out.  There were a couple smaller ones, both about an inch in diameter that came out much easier.  The unfortunate part of this patient’s problem is both tubes were diseased from previous infection and one was completely blocked.  Her chances of conception are very poor.  The fibroids certainly can interfere with pregnancy.  The patient has tubal disease which makes it even more difficult to conceive.  Unfortunately, there is not much we can do to help her at this time.

Our second patient who called in stating she had malaria really doesn’t have malaria.  We learned this morning that she is afraid of undergoing surgery so she made up the story about having malaria.  She has not come in and we will likely not see her.  This leaves us with just one more surgery which is a D&C for a fibroid inside the uterine cavity.  This patient also wants to conceive. 

Yesterday we saw a patient who was pregnant at about 16 weeks and had a gush of water.  She had been told she needed a D&C to evacuate the uterus; however, she had fetal heart tones.  She was hospitalized at the local hospital and they were waiting for the gynecologist to come in a couple days to take care of her.  She came to the clinic for an evaluation.  I saw her yesterday and did a sterile exam on her finding a closed cervix and no evidence of leakage of water.  She was about 16 to 18 weeks size.  We recommended she stay at bed rest and to call if anything else happened.  This morning she had a sudden urge and then expelled the fetus.  She came in and exam reveals a fetus with attached umbilical cord but no placenta.  We put some Pitocin in her IV and will see if contractions will then empty the uterus.  We may have to do a D&C on her.

After some Pitocin she began bleeding heavily and we took her to the OR to extract the placenta.  I had to do a D&C to get the placenta out and stop the bleeding.  She lost probably a unit of blood within 5 minutes and probably more than that overall.  I was able to extract the placenta and then with a couple IVs with Pitocin she slowed her bleeding significantly.  Jane told me she was really glad I was here to help with this situation. 

1:00 PM.  We have just finished lunch.  Loida made ceviche, a cold soup with shrimp, diced onions and other spices.  It is absolutely delicious and when Loida makes it, it is even tastier.  She made the ceviche just for me and I appreciate that so much.  The cold soup can be eaten like a soup or poured over cooked rice.  What a great lunch and special treat!

1:30 PM  We are starting our last surgery of the day.  This patient has a 2 cm mass inside the uterus.  On ultrasound it is difficult to tell if this is a polyp or fibroid.  It is on a short stalk and we hope we can remove this with a D&C.  Dr. Chang planned to give her a short general anesthetic using an oro-pharyngeal airway.  As we were positioning the patient she began vomiting and her airway filled with vomit.  Dr. Chang immediately removed the airway and used suction to clear out what ever was in the pharynx so she didn’t aspirate.  Fortunately, she didn’t get any in her lungs.  Once she woke up she admitted that she had just eaten an orange before coming in even though Jane had told her to not eat for at least 6 hours before coming in for surgery.  This could have been a disaster but fortunately that was averted.  After making sure the lungs were clear and there was no problem from the vomiting, Dr. Chang then put in a spinal anesthetic so we could do the surgery.  The D&C went well with removal of a 2 cm fibroid.  The uterine cavity was smooth and symmetrical after the procedure.  This saved this patient a major surgery and possible hysterectomy and will likely take care of the cramping that occurred with her menses.

Father, thank You for helping us today.  The first surgery was quite difficult yet You made it possible to remove the fibroids without injuring the uterus.  For this we are extremely thankful.  Thank You also for watching over the patient who lost her pregnancy.  This has to be a sad moment for the parents, especially the mother, to feel movement and then have the pregnancy come to an abrupt end.  Thank You for protecting her from significant bleeding and problems.  Thank You, Lord, for guiding us through the last surgery and removal of the intrauterine fibroid.  This was not easy, Lord, yet You enabled us to get the job done and save this patient more surgery and problems.  Lord, You are so gracious to us and Your love for us overwhelms me.  Thank You, Lord for all You do for us.  Amen.

7:15 PM.  I have spent some time packing some of my clothes so I don’t have to scramble tomorrow night.  Our surgery day tomorrow will be long as we have 5 cases scheduled.  We leave Saturday morning for Quito and I will need to have everything packed in my carry-on and backpack.  It doesn’t always go in the suitcase as easy as it came out.  We met for dinner and had some soup and rice.  Jane and I then rounded on all the post-op patients.  The patients are all doing very well.  I am pleased to see this.  Each of these women had some big surgery and even at 24 hours post-op they are up and about and having normal bladder function.  I am always amazed at the pain tolerance these people have.  Usually after a major surgery the patients will stay comfortable taking one tablet of Vicodin about every 6 hours.  They don’t complain of pain and many times will take very little pain medication.  Jane will give them a small packet of 6 tablets and usually when they head home they still have most of the pills left.  Compare this pain medication usage to what I see in the States and the difference is amazing.  In the States we have people on IV pain control, getting regional blocks, taking lots of pills and not getting back to work for 4 to 6 weeks.  Here the people go home in a day or two and resume normal activity in a couple days more.  It is interesting to see the difference in pain management.

I will soon be heading to bed for another nine hours of sleep.  I have slept more soundly here in the noisy city of San Lorenzo than I sleep at home.  I don’t understand why.  Maybe it is because I am more tired than I realize when bedtime comes.  It could be once I am in bed and under the mosquito netting, I am trapped there with nothing to do but to close my eyes and sleep.  At any rate, the sleep has been good and I am thankful for that with all the difficult surgery we have had this week so far.

Father, this week is almost over and You have empowered us to accomplish a lot for the people here in San Lorenzo, Ecuador.  Thank You for this opportunity to come here and serve You through serving the people here.  It is a special blessing to partner with You to bring healing to someone.  Father, thank You for allowing me to walk with You here, to follow You here, and be Your hands and feet here.  Lord, I pray for a good night’s rest for everyone on our team so we can be fresh and ready for tomorrow.  Thank You, Lord!  Amen.

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