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7/15/09 (Wednesday)

Wednesday, July 15, 2009

6:15 AM.  I wanted to round with Jane this morning to check on the patients.  So, I am up and showered and ready for the day.  Jane and I will see all the recovering patients before breakfast at 7.  Again, sleep was fairly good in spite of the sweat and humidity.  With all the sweating I still am storing a lot of water in my legs.  This morning the edema was down from 4+ to 2+ but still definitely there. 

Jane and I rounded on all the post-op patients.  They are all doing quite well.  The lady who had the gastric resection is a little worrisome because of a rapid pulse.  She is anxious and yesterday was worried she was going to die.  We brought her over to spend the day in the recovery room so we could keep an eye on her and she did very well, was comfortable, and enjoyed the day.  So far there have been no significant findings except for a rapid pulse.  She sat up in bed this morning without difficulty or dizziness.  We will watch her closely today.  The little old man who had the hernia looks great and is up and about with minimal complaints.  He had almost all of his pain medicine still sitting by his bed and he is not complaining of much pain.  His only comment was he hasn’t passed any gas yet.  I am amazed at the pain tolerance these people have.  Either they are not in pain or they are so used to pain and take it in stride without any problems.  Our ladies from yesterday look great and are having no problems.  Watching these people recover from major surgeries without near the intervention we utilize at home to keep the patients comfortable is an amazing sight to me.  These people get up quickly, eat quickly, require very little in pain management and go home early.  Jane will give them about 6 pain pills on the first day and usually there are still 6 pills yet to be taken by the next day’s visit. 

Father, Your grace and mercy are incredible.  You have showered our patients with Your presence and healing power and provided for us in so many ways.  Thank You, Lord!  I pray for the patients who are recovering.  Please continue to provide healing for them.  Especially, Lord, cover the lady with the gastric cancer surgery with Your love and draw her close to You.  Protect her and heal her, Father.  Thank You, Lord.  I pray for the people we will be operating on today, Father.  Please protect them as well.  Guide our thoughts and hands and help us do the right surgery for these people.  Help us be Your instruments of healing.  Thank You, Lord for this opportunity to serve You.  To You I give all the praise.  Amen.

Our surgeries today will be a variety of cases.  We will be doing another hysterectomy and then will be following this surgery with the vesicovaginal fistula repair.  That should be an interesting surgery.  Following that is a tuboplasty and then our last surgery will be excision of multiple condylomata. 

Our first patient:  J.A. is 39 and has had troublesome bleeding that has not been responsive to medical management.  She has some uterine fibroids which may be part of the bleeding problem.  We will be managing this with a simple hysterectomy.  At surgery we found an enlarged fibroid uterus but no other problems.  The surgery went well with no complications.

10:45 AM.  We are finished with our first surgery.  At this time my father’s funeral is underway.  Again, I am hit with mixed emotions.  I wish I could be there to support my brother and sister and my wife.  Yet, I am thousands of miles away working in a mission project being an instrument of healing for the people God led me to.  I know Dad would want me here and would not want me to go to extra measures to come home for his funeral.  This transition into eternity was something he longed for and was prepared for.  That gives me peace and comfort.  Thank You, Lord, for my father and the legacy he leaves for his children.  He taught me and prepared me for life.  Thank You for giving him a full life.  Thank You for preparing him to live with You forever.  Thank You for inviting him to trust in You and to make You Lord and Savior in his life.  He taught that to me.  Thank You, Lord, for Dad.  Amen.

Jane, Angelita, Maria Luisa, Nyletta, Piedad, Damarys all gathered around me and sang a hymn to me about the glorious arrival in heaven for all who believe in Jesus.  They dedicated this to my father and to give me encouragement.  This was a very moving experience for me and was very special to help me through this time.  Jane thanked me for staying to help with all the surgery and I told her that Dad would have preferred me to be here instead of coming home.  Dad, this little gathering and song of praise was for you.  I know you are here with us and we give you a tribute.  Thank You, Lord, for this act of kindness and compassion on the part of these special people here.  I so appreciate them and love them.  Thank You for giving me peace and comfort at this time.  Thank You, Lord.  Dad is in Your presence now and has achieved his life-long goal.  Thank You for that, Lord.  Amen.

The next patient, V.G. is 36 with a history of not being able to conceive for several years.  A salpingogram reveals what appears to be a normal tube on the left out to the end but no spill of dye from the tube.  The right tube fills to the mid portion and no further.  On x-ray the tubal canals appear as they should be for healthy tubes.  Our plan is to evaluate with a minilaparotomy to see if the tubes are fixable with a tuboplasty.  At surgery we found totally normal tubes with no evidence of tubal disease or any obvious reason for infertility.  This is good for her to not have some disease process that would make conception difficult or impossible, but it is very frustrating as well.  She is left with the persistent problem with no answer or explanation.  When all you find is normal anatomy it becomes very difficult to understand why the system doesn’t work as expected.  It is even harder to explain this to the patient so she can understand.

1:30 PM.  We stopped for lunch.  Nancy served us squid in coconut sauce over steamed rice.  It was absolutely delicious.  In addition she served a medley of radishes, green beans, onions, tomatoes in a lemon sauce.  She then gave us some fried banana which is a favorite of mine. 

2:15 PM.  We are now preparing for our third surgery which was originally the fourth.  This lady, A.C. is 28 and has multiple condolomata of the vaginal opening and genital area.  Jane has been treating these with topical therapy but there are too many to see any good response.  Our plan is to remove all we can see with surgical excision and cautery.  Jane and I were able to excise and cauterize all the lesions visible under magnification.  Any new lesions that may appear can more easily be controlled with topical therapy.

Our last  patient: C.P. is 56  and has a vesicovaginal fistula.  I reviewed the IVP last evening with Jane.  The IVP shows normal kidneys on both sides with a complete duplication of the ureter on the left.  The two ureters join right at the bladder wall.  The fistula could not be seen clearly but dye did spill into the vagina causing the vagina to be outlined on the x-ray.  Our plan is to approach this abdominally by opening the bladder and carrying the incision down to the fistula.  We then excise the fistula tract from the bladder wall and then remove the other end of it from the vaginal wall.  Then we close both structures and interpose some peritoneum or omentum in the space between the bladder and vagina to help prevent any redevelopment of another fistula.  At surgery we found a fistula, a hole about 5 mm in diameter that connected the bladder to the upper vaginal canal in the midline.  By opening bladder we were able to incise down to the fistula and excise the fistula tract.  We then closed the vagina and covered that closure with peritoneum.  Then the bladder was closed.  During this closure the anesthesiologist gave the patient some methylene blue solution intravenously.  In about 5 to 10 minutes blue urine started spurting from the ureteral orifices in the bladder.  This patient had complete duplication of the left ureters and we saw two ureteral orifices on the left side of the bladder.  When the blue colored urine came through from both sides, this signified the ureters were intact and we had not compromised them.  The patient will need to wear a catheter for a couple weeks to allow time for the bladder to heal.  Then she should be back to normal urinary function and won’t have to wear a diaper all the time.  I am sure this will be a significant improvement in her quality of life. 

7:15 PM.  Our day is done and we are back at the house.  Soon we will have our supper and then it will be time to go to bed.  Tomorrow is another big day with a long case in the morning. 

Lord, thank You for a good day in surgery.  Again, You were there with us and held our hands as we worked together with You to accomplish the surgical procedures.  You also held the hands of our patients and gave them peace and security.  Thank You for giving us the wisdom we needed to do what was right for the patients.  Thank You for sending Paul to us for our anesthesia.  He is a great team player and we have truly enjoyed working with him.  Thank You, Lord, for bringing together all the people on the team here.  Everyone has an important role in making this clinic what it is.  Lord, they all participate in a ministry to the people who walk through the front gate seeking care.  This ministry not only brings physical healing but also spiritual healing.  Thank You for working out all the details to make this happen.  Father, thank You especially for the very kind encouragement the team gave me this morning at the time of Dad’s funeral.  That was so meaningful to me and this was part of Your comfort and encouragement You extended to me.  I was not expecting this yet You sent it my way anyway.  It was a message of love and I so appreciate that.  Thank You again, Lord, for a good day. It is such a thrill to serve You in this way.  Amen.

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