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7/20/2012 (Friday)

Up by 6 am and then refreshed quickly in the cold shower.  I then had some breakfast and then spent some time studying a section in a book I am working through on developing a more productive quiet time with God.  Today’s reading was about maintaining the attitude of thanksgiving in the face of trials.  One comment by the author jumped out to me:  “Christianity is not a bridge over troubled water.   Jesus said, “In the world you have tribulation” (John 16:33), and he said that so the disciples wouldn’t be surprised when it happened.  The joy of Christianity is not the absence of difficulties but the presence of God.”  That last sentence was so encouraging to me.  At times when we face trials and suffer pain, our thoughts are everywhere else but on God.  Pain is a great distracter and the evil one uses that tremendously to accomplish that.  Look at Job, for instance.  Yet, he didn’t give up on God and in fact enjoyed the very presence of God through all his trouble.  I have experienced this myself and heard it from others that in the midst of pain and trial one feels closer to God.  Maybe that is because all our props are taken away and the only hope we have is God.  Think on those words again – “The joy of Christianity is not the absence of difficulties but the presence of God.”

We then met with the team for morning devotions.  The scripture we studied was Luke 16: 19-30.  Here Jesus is telling the story of Lazarus and the rich man.  The question that floated around the table was “Do we think of our own mortality?”  How prepared are we to face God if that came today, this minute?  Are you ready?  We should be prepared to meet the Lord.  What I gather from this story Jesus told are some facts about the place called Hell.  First, Hell is real.  Why would Jesus talk about something that was false?  Second, Hell is eternal, unending…without God.  We have so much of God around us.  God is light and think about spending eternity without light…total darkness.  I have even read from some authors that in Hell you are alone, totally alone, without any contact with anyone else.  Think on that for a minute – totally alone, in complete darkness.  Thirdly, the rich man, and he likely represents any person, is completely aware of his torment.  He is not dead at all but in conversation with Father Abraham.  He expresses his pain and torment and desires if anything to warn his family so they would not be subject to the same destiny.  When you think of what Jesus is telling us about the reality of Hell, why would anyone joke about it and live a life where that would be his or her destiny?  Think how much more torment one would experience if you had to suffer this in the absence of God?

Father, I am overwhelmed with what I read initially and we read together today.  Thank You so much for the incredible gift of salvation!  This is a measure of Your unfailing love to take me, so deserving of condemnation and eternity apart from You and granting me through Your Son the gift of eternal life in Your presence, bathed in Your love, illuminated by Your light, experiencing no more tears, pain, agony, uncertainty, doubt, or sin.  Lord, saying Thank You doesn’t seem to be the right words.  They are the best words I can come up with but still they seem to fall short of what my heart wants to say. 

Father, I pray for our day today.  Please surround us with Your wisdom and discernment.  Give us patience as we talk with these people and determine their difficulties and then decide what to do to manage the problems.  Lord, we fully depend on you for all of this.  There is no other source of strength we have but You.  Thank You for bringing me here.  Thank You for bringing Jane into my life professionally and how well we work together with a common vision, common purpose, and relying on a common source of strength and wisdom – You.  Father, I commit this day to You and desire with all my heart to bring all the honor and glory to You.  Thank You Lord!  Amen.

8:45 am.  We are in the clinic and ready to see the patients on the schedule for today.  Some may not be candidates for any surgery.  Jane has part of the schedule already determined.  We will finish the schedule today. 

Clinic patients: (I apologize for the clinical language…just force of habit.)

  1. M.O. age 46.  I saw her last November and at that time she was having urinary incontinence with cough and sneeze.  We were concerned about how well a vaginal repair would hold in the long run and recommended a hysterectomy with repair of support from above.  She did not want to go through this type of procedure and requested a mesh insertion to correct the bladder function.  We did not have the mesh available.  In the interim she underwent a hysterectomy and mesh insertion in February 2012 under the care of another physician.  She now comes in complaining of a lot of pain in the lower vagina.  Exam reveals considerable tenderness along the vaginal incision where the mesh was inserted.  There is a lot of redundant mucosa.  There is no evidence of mesh erosion.  It is hard to determine what is causing the pain.  The mesh could be eroding and we just can’t see it yet.  Our plan is to open the vaginal incision and excise the area of tenderness and evaluate the mesh.  These problems are difficult to manage when you did the surgery.  They are even more difficult when someone else did the surgery and you don’t have a good idea of what was done at that time.  Plus, it is very difficult to give this patient a good prediction that this surgery would eliminate her pain.  We may not accomplish anything in the long run.  But yet, we have to try.
  2. M.M. age 47.  Underwent abdominal hysterectomy 6 years ago and was told the left ovary was removed.  Two years later she underwent surgery to remove a retained sponge.  She said the doctors talked to the family about removing a mass, a tumor, in her abdomen.  However, the patient states she distinctly heard the nurses talk about the mass being a retained surgical sponge.  The doctor never did tell her what really happened.  Since the first surgery she has had persistent right deep pelvic pain.  Exam reveals tenderness in the right lower quadrant of the abdomen with deep palpation with no mass discernible.  Vaginally, there is a 2 cm mass attached to the right vaginal apex.  This is very tender.  I suspect the right ovary is adherent to vaginal apex.  The left ovary not palpated; however an ultrasound shows both ovaries present with follicle cysts.  Our plan is to perform an exploratory laparotomy with probable removal of right ovary as this appears to be the source of the pain. 
  3. A.Z., age 38, possibly 42.  Stated age is 38.  DOB projects 42.  She is now married to new husband and wants to conceive.  One previous pregnancy 15 years ago ended in spontaneous miscarriage.  Work-up so far reveals a marginal sperm count of 25 million with normal findings otherwise, hysterosalpingogram (HSG) that suggests bilateral obstruction at the cornua (the junctions of the tubes with the uterus), and posterior intramural fibroid of 3 cm.  We talked with patient and husband explaining the problem with the tubal obstruction.  Our chances of re-establishing tubal patency are very low if the obstruction is in the cornua as the HSG suggests.  We recommended a minilaparotomy to assess the tubal anatomy and determine if tubal reconstruction is needed.  Also, will look at fibroid to determine if it needs removed as well.  There is a good chance of not being able to do anything and they understand this. 
  4. R.R., age 50.  Has stress urinary incontinence (SUI) and Jane had instructed her on Kegel exercises.  Her SUI is now much better.  She is in for evaluation of large mole on left side of her face.  Jane biopsied this earlier and it showed no melanoma.  The patient wants it removed.  Jane will do this under local anesthesia on Friday afternoon since our anesthesiologist is planning on leaving about noon on Friday.
  5. R.B., age 62.  Has large rectocoele on previous exams.  This is not too symptomatic and bowel function is okay.  She states she has had some heart disease but functionally is doing well.  The exam reveals a normal uterus with minimal descensus or prolapse.  There is good anterior vaginal support and a large rectocoele in the posterior wall.  There is no enterocoele.   Our plan is a posterior repair.
  6. This patient came in unexpectedly with an abscess of left axilla.  Jane had treated a cellulitis in this area last week and has had her on antibiotics.  It now has developed into an abscess.  Jane opened and drained it  in the office.  The lady lives in Colombia and is very poor. 
  7. M.A., age 22, has vesico-vaginal fistula for 3 years.  Jane had told her to come in when I was here so we could consider surgical repair.  However, Jane lost all contact with her and couldn’t confirm if she would appear.  Then, today she walked in the clinic ready to be seen.  She delivered 3 years ago after a prolonged labor (4 days).  Immediately following delivery she began leaking urine from vagina.  The exam reveals a small fistula, about 2 mm, located at mid-vaginal area to the right of the urethra.  Urine flows with valsalva (straining or cough) but there is no continuous flow that would may one think of a fistula to the ureter.  The location of the fistula points to either a hole from the urethra to the vagina or from the bladder to the vagina.  It is small and should be easily treated surgically.
  8. J.A., age 34, with history of HPV in the past and this has spontaneously cleared.  Paps have been completely negative.  Last pap was January 2012.  She has been very worried about cervical cancer and keeps coming in for pap smears.  She was in one month ago and Jane found her exam normal.  The Pap was not done because of three previous negative paps over a short period of time.  She presented today declaring an emergency wanting to be seen immediately for another pap smear.  She saw a non-MD practitioner last week who told her she has the “virus.”  She is in today terrified and crying.  Exam of external genitalia and vagina and cervix reveals totally normal findings.  The practitioner apparently painted the external surfaces with some iodine solution and then told her she had the virus.  The patient has been an emotional wreck since then.  We reassured her that her exam is normal and we see no evidence of the virus.
  9. L.R., age 52, presents with history of skipping menses at times and developing right sided pain.  She obtained an ultrasound and this shows “adnexitis” of the left and cervicitis but nothing on the right.  I am not sure how one can visualize inflammation of the tube and ovary on ultrasound unless there is profound swelling and fluid.  The ultrasound was otherwise normal especially on the left side.  The physical exam shows some mild tenderness in the lower mid to right abdomen with no mass palpable.  The pelvic exam was all normal and no tenderness of adnexae.  I suspect the pain is not gynecologic in origin and Jane and I recommended observation and reassurance.
  10. E.Z., age 64, with stress incontinence.  Has been on Kegel exercises for a year.  She saw Jane a year ago with the urinary problems and Jane prescribed the Kegels.  However, the exercises have not had much effect.  She has had an abdominal hysterectomy in the past.  Exam shows a moderate cystocoele with urethral descensus with cough.  There is a midline fascial defect over the cystocoele and no rectocoele.  Plan: anterior repair for cystocoele and SUI.
  11. D.C., age 31, with recent problems with pelvic pain.  Recent exam by Jane showed tenderness.  Jane treated her with doxycycline for suspected PID.  The pain has been present for 5 years.  She has had a previous tubal ligation.  Ultrasound shows some small fibroids in uterus but no other problems.  Exam shows some tenderness to deep palpation in the right side but no mass.  Pelvic exam shows a slightly globular uterus that is very tender over the right margin and cornua.  Palpation of this reproduces her pain.  The right ovary is normal and not tender.  The left is also normal.  I talked with Jane about management.  Most likely a hysterectomy would be the best treatment and she could do this at another time than next week. 
  12. I.R., age 51, has a vaginal bulge after standing for some time.  Her bladder function is normal with minimal SUI.  Exam: large cystocoele that prolapses through the introitus (vaginal opening) with valsalva.  The uterus does have some descensus but minimally.  Adnexa (ovaries and tubes) are normal.  Our recommendation was a cystocoele repair (anterior repair) but she did not want to proceed with surgery at this time. 
  13. E.L., age 78 to 80, has a mass hanging out of vagina when standing.  Bladder function is normal with no incontinence.  General health okay.  Exam: large cystocoele that converts into complete vaginal prolapse with valsalva.  Uterus is small.  There is a large enterocoele and rectocoele.  These problems are difficult to manage surgically as the entire vagina is turned inside out and the anatomy is so distorted.  Our surgical goal is to restore the normal anatomy.  That is easy to say but sometimes very hard to do.  She travelled 2 days to get here having come from Ecuador but crossing the river into Colombia and then back across to Ecuador. 
  14. M.H, age 76.  Delivered 21 babies!  Has a cystocoele that prolapses out.  She said she didn’t need a doctor around to deliver her babies.  The root words for obstetrics is ob & stare  meaning to stand by.  That what I did when I practiced obstetrics.  However, this lady didn’t even need anyone to stand by.  The cystocoele falls out when she stands.  Needs a walking stick to help her walk because of arthritis in the knees.  Exam shows a large cystocoele and moderate uterine prolapse.  Imp: cystocoele.  Plan anterior repair.
  15. L.C., age 64.  Has post menopausal bleeding and endometrial hyperplasia with atypia on D&C.  This change in the endometrium is precancerous.  She has had one endometrial biopsy and two D&Cs with progression from simple hyperplasia to atypical hyperplasia.  I have seen her twice in the past.  With the progression of the endometrial changes, hysterectomy is now recommended.  We will proceed with this surgery on Monday.

Surgery schedule for next week:

Monday: Hysterectomy, laparoscopic cholecystectomy and D&C, vesico-vaginal fistula repair, anterior repair

Tuesday: Hysterectomy x3, vaginal hysterectomy with repairs for total prolapse

Wednesday: Thyroidectomy, vaginal exploration, laparotomy with right tube and ovary removal                   

Thursday: Laparoscopic cholecystectomy, hernia repair x2, minilaparotomy to evaluate tubal status                 

Friday: Removal of mass from right hand, anterior repair, posterior repair, excision of nevus on face

Father, our clinic evaluations are now complete and we have our work cut out for us next week.  The surgeries scheduled are likely to be challenges and yet we know You are there with us and You wrap Your hands around our hands and guide us through each surgery.  Father, I pray for each of these patients.  They are facing some difficult surgeries and the potential of complications is certainly present.  However, I am reassured once again through what I read this morning that our hope and our joy in the midst of challenge, trial, turmoil and even torture is Your loving presence.  Thank You, Lord.

3:30 pm.  We finished with the clinic and took a break for lunch.  After a sandwich and some tangerines (which are delicious) I returned to my room to think through the day and get some rest.

6:00 pm.  The church that meets in the ministry center here on the clinic grounds has a praise team that just began practicing.  The ministry building is a pavilion that has open walls and a roof.  The sound reaches out to the city, which is good when you are preaching the good news.  However, when the music is dissonant and painful to listen to, then one wonders what message is being given.  Jane said the praise team is comprised a few young people all of whom cannot carry a tune in a wheelbarrow.  They think they have the most wonderful voices and sing as loud as they can.  Add to that the keyboard and the sound system turned up full blast and it all becomes a cacophony of noise.  I was thinking of using my down time right now to study more on developing a quiet time with God.  I am not sure that will happen now.  Of course, I keep reminding myself that we are instructed to make a joyful noise unto the Lord and that is what they are doing.  God doesn’t care if it is music or dissonance.  Why should I?  Yet, my ears want to protest.  Soon the boom boxes and stereos in the neighborhood will be going full blast as well and this will continue on into the night.  The joys of San Lorenzo!!

10:00 pm.  Time for bed.  Jane fixed dinner using her crock pot to cook some chicken breasts and some garlic and herbs salad dressing poured over them.  This cooked all day and they were absolutely delicious.  Makes for an easy preparation of this two-step recipe – put in the chicken and pour in the dressing.  We had a good meal and now I am ready to turn the lights off and listen to the sounds of San Lorenzo on a Friday night.  The only thing missing is the praise team practice.  Otherwise the stereos in the neighborhood are going full blast and occasionally a dog barks through the music.  I have slept through the roosters early in the mornings so far.  The fan running all the time provides a nice white noise barrier to all the strange sounds drifting in through my windows.  I was able to connect with Phyllis tonight on Skype and enjoyed conversing with her.  I wish she were here with me.

Father, this has been an interesting and productive day.  We have next week planned out for us and we are ready to move into that work You have called us to do.  For now, though, rest is in order.  Thank You for that.  I pray for my family, Lord.  Please bless them in a special way tonight.  I pray also for the many friends who are praying for Jane and me.  Thank You for them, Lord.  They are a special blessing to us.  Thank You, Lord, for Your protection and provision.  Thank You, Lord, for Your encouragement and empowerment.  Thank You, Lord, for forgiving us when we fail You and then restoring us and never turning Your back on us.  I pray now for a restful night.  Thank You, Lord!  Amen.


1. Leslie Melcher - July 20, 2012

Hi there. Thanks for the update. Sure glad you are feeling better. That is quite a full week of surgery you have laid out. After all your working visits, it must feel like a second family there. May God bless you and the entire team for all you do for others.


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