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7/10/09 (Friday)

Friday, July 10, 2009

Up by 6:15 and refreshed after a cold shower.  We had a good rain last night and the cistern is now full for the moment.  There was a moderate amount of thunder and lightning.  We then had breakfast and the met with Angelita and Maria Luisa for devotions.  After devotions Jane oriented Steven and Nyletta with the jobs they need to do for the morning and we went on up to the clinic to start seeing patients.

Lord, thank You for this day, a beautiful day that is just routine for You.  I pray we can render good care to the people coming in to see us.  I pray also we can display and share the love of Jesus to these people.  Thank You for the opportunity.  I pray also for my father who is in a coma and appears soon to pass on into your presence.  Please comfort him and communicate with him as You certainly can pass all the barriers that we can’t understand or manage. Thank You, Lord.  Amen.

List of the patients evaluated today:

  1. V.M. is 39 with one previous pregnancy 10 years ago delivered by C-section.  The baby died about 8 months later of an acquired disease.  She has been unable to conceive since.  A salpingogram reveals normal tubes to the distal ends with what appears to be small hydrosalpinx formation bilaterally.  She is in good health.  We talked with her and will schedule her for a bilateral cuff tuboplasty.  I feel she should have a good result.
  2. M.L. is 32, healthy, one pregnancy 16 years ago.  Ten years ago a hysterosalpingogram revealed bilateral tubal blockage.  She has had no symptoms or history of pelvic disease.  She did not repeat the HSG.  Plan is to evaluate at surgery and repair as indicated.  Jane said sometimes the previous doctor might tie the tubes without the patient knowing about it.  We told this lady we may or may not be able to help her and we can only decide once we see the status of the tubes.
  3. M.C. is 25 with no previous pregnancies, single, not sexually active.  History of dysmenorrhea that is most intense at onset of 7 day flow.  An ultrasound shows a small 11 mm myoma in the uterine fundus.  She has had a lot of pressure from a grandmother and other people to undergo surgery and even have a hysterectomy.  She wants to eventually conceive.  We will proceed with a small laparotomy to remove the myoma and perform a tubal dye study to assess the tubal patency. 
  4. V.G. is 35 with no previous pregnancies.  HSG reveals possible tubal blockage on the right and no spill on the left even though the tube fills.  General health has been excellent with no surgeries.  Our plan is to evaluate with a laparotomy and assess the tubal patency and repair as indicated.
  5. C.C. is 56 with a history of something bulging from the vagina associated with constipation.  To defecate she has to push on her perineum to enable passage of stool.  Her health is good with no significant history.  Twelve pregnancies uneventfully.  On exam she has a prominent, well defined rectocoele that involves the distal half of the posterior vaginal wall.  There is no cystocoele or uterine descensus.  Our plan is to perform a posterior repair.
  6. R.O. is 62 with stress incontinence for 28 years.  Jane’s exam showed an urethrocoele.  Her health is good, no previous surgeries, 9 pregnancies.  She has easy leakage of urine with minimal straining.  Exam reveals a prominent cystourethrocoele with multiple vaginal varices in the mucosa.  There is an annular constriction of the upper vagina at the upper limit of the cystocoele.  The pelvic exam otherwise was normal and there was no rectocoele.  Our recommendation is an anterior repair.  Because of her family situation and other pressures, she is quite reluctant to have any surgery.  She wanted a pill to fix her problem.  With her having some urinary pain, we will try some Bactrim for 5 days for the time being.
  7. M.M. is 51 and is perimenopausal.  She is having intermittent bleeding with skipping of cycles followed by very heavy flows.  Recently she needed transfused with 2 units of blood to correct a bleed down to 6 gm hemoglobin.  She has been taking various hormonal preparations prescribed by various providers.  She also was advised to have a hysterectomy in the past.  At this point she is not bleeding and has a hemoglobin of 10.3.  Plan is to stop all hormones and observe.  Start on iron replacement and recheck hemoglobin if another bleed occurs for more than 4 days.  Then I would push for a hysterectomy to gain effective control of the bleeding.  My suspicion is she is developing endometrial hyperplasia that will bleed periodically, at times heavy.  The hormone preparations have confused the situation.  Hopefully, she may be able to ride it out and complete menopause and stop bleeding.  If not, hysterectomy would be the best option.
  8. R.M. is 39 and recently underwent surgical treatment for colon cancer.  She recently had a pap smear that returned normal with a recommendation to repeat it in 3 years.  She came in for a consult only.  She was opportunity is there for detection of any pelvic disease, especially cancer recurrence, and for a yearly pap since her colon cancer was nearby.  She said she was having a little bit of vaginal itching so we treated her with some clortrimazole vaginal cream.
  9. N.A. is 39 with pelvic pain and a left ovarian cyst.  Recent ultrasound on 6/20/09 showed a 5 cm cyst on the left ovary.  The ultrasound was of very poor quality and Jane had recommended a repeat scan.  She had a normal period on 6/22/09 and then had another ultrasound on 7/9/09.  This scan shows the left side to be completely normal with no cyst and a 3 cm follicle cyst on the right.  Pelvic exam confirms these findings.  My impression is the left side was a corpus luteum cyst that spontaneously resolved with the completion of the cycle and now she has a normal follicular cyst on the right.  Recommendation: Observe, reassurance.
  10. R.H. is 46 with a vesicovaginal fistula that on exam is located in the right upper vaginal apex.  This occurred post hysterectomy performed in Quito about 1½ years ago.  She has constant urinary leakage necessitating a diaper all the time.  Exam reveals a fistula tract in the upper vagina about 2 cm from the vaginal apex.  There is an annular constriction around the vagina at the level of the fistula.  Beyond the constriction ring the vaginal apex is normal.  Both lateral corners are not involved.  I suspect this is a fistula that originated from a vaginal suture that penetrated the bladder.  We will cannulate the fistula at the time of surgery and then approach this abdominally to open the bladder and remove the fistula.  I feel this lady has a very good chance of returning to normal bladder function.  When Jane told her she would need to wear a catheter for a couple weeks post op, she just shrugged and said, “That’s better than a diaper.”
  11. N.A. is 36 and has had a tubal ligation 6 years ago.  She wants to conceive again.  A hysterosalpingogram shows the right tube to fill to the distal end with no spill.  The left tube fills to the mid portion of the tube.  I suspect a fimbriectomy was performed on the right and a standard tubal ligation on the left.  We will proceed with a laparotomy and assess the tubes.  The left might be a reanastamosis and the right a cuff tuboplasty.
  12. J.P. is 40 and has worn a copper-T IUD for several years.  She wants it removed and the string is not visible on exam.  An ultrasound also confirms the IUD is in the uterine cavity.  We will do a D&C to remove the IUD.
  13. M.Z. is 45 and has a large pelvic mass.  Ultrasound shows large myomatous uterus.  She has had some heavy menstrual bleeding and bled the entire month of May.  Jane felt a large mass on exam and has her scheduled already for a laparotomy and hysterectomy.  On exam she has a large uterine mass extending 3 cm above the umbilicus.  The mass feels soft and lumpy.  We will proceed with hysterectomy.
  14. C.V. is 58 and recently saw Jane for a pap smear.  At exam Jane found a strange polyp-like lesion on the cervix.  She asked her to come in so I could examine her.  On exam she has a large endometrial polyp prolapsing through the cervix.  The polyp is 1 to 1.5 cm in diameter and extends beyond the cervix by 1 cm or more.  I recommend a D&C and polypectomy
  15. R.C. is 28, never been pregnant and wants to conceive.  Ultrasound reveals a 4.6 by 5.7 cm intramural myoma.  She is being considered for a myomectomy to improve her chances of pregnancy.  Exam reveals a 14 week size uterus that is tender.  The large myoma appears to be central in location.  Her menstrual function is normal.  We will proceed with a myomectomy procedure.
  16. G.C. is 76 and comes in with complaints that something is falling out of the vagina.  She gives a normal bladder history with no incontinence problems.  She does state she has urgency and must get to the bathroom quickly and at that time she may leak a little.  She comes in with a walker because of a failed spine surgery where what sounds like disc disease resulted in surgery causing shooting electric pains down both legs.  It appears this poor lady got the worst end of a surgery gone wrong.  I feel really bad for her in that she now must live with the mistake and suffer every day.  On exam we did not find any significant pelvic relaxation.  We did prescribe some Bactrim to see if this might help the urgency and Jane gave her some pain medication for her back.  What a struggle this lady must go through every day.  She can barely walk with the walker and is in constant pain.  Father, please love this poor lady in a special way today.  Touch her with Your healing touch and bring her relief from her pain and disability.  Give her hope, Lord.  Thank You.  Amen.
  17. A.C. is 28 and has been struggling with vaginal and vulvar condylomata.  Jane has been treating her topically for some time with some control but not clearance of the lesions.  She is in today for my evaluation and recommendations.  On exam she has an abundance of condylomata covering the vulvar surfaces and the vaginal introitus.  There appears to be no involvement up in the vagina or on the cervix.  The condylomata have increased in size and number according to Jane.  She has a mixed vaginitis with abundant discharge as well.  We plan to treat her with Betadine douche twice daily and schedule her for surgery for electrocautery of all the condylomatous lesions. 
  18. A.M. is 50 and has had a hysterectomy a few years ago.  Recently she has had some vaginal bleeding and Jane has noted what appears to be some granulation tissue on the vaginal side wall.  Exam reveals a small tag of granulation tissue on the left vaginal sidewall near the apex.  Our plan is to excise this lesion under local with sedation.

Our surgery schedule includes these procedures:

Monday:  Subtotal gastrectomy for gastric carcinoma, tuboplasty, myomectomy, and an incarcerated inguinal hernia.

Tuesday:   Abdominal hysterectomies X 2, (there is one, possibly two more who have seen Jane recently who are scheduled to come for surgery next week.  We will save time for them on this day.)

Wednesday:  Hysterectomy, vesicovaginal fistula repair, tuboplasty, electrocautery of condyloma

Thursday:  Excision of a parotid gland tumor, posterior repair, tuboplasty, D&C X 2

Friday:  Tubal ligation X 2, umbilical hernia, tuboplasty, myomectomy

The typical gyn surgery schedule…in one day I am ligating tubes to provide permanent sterilization and also undoing the same procedure to reverse sterilization so conception can occur! 

I keep wondering how my father is doing at this time.  I wish I could be there to talk to him but in a comatose state one wonders if he would even know I was there.  With the rather dramatic change in his consciousness and condition, I wonder if he had a major stroke.  According to my brother’s email, the nurse at the nursing home said he was in the final stages of leukemia.  We knew he had a condition that was a pre-leukemia state and had been on some chemotherapy for this but could not tolerate it.  However, we have never been told that he had leukemia.  This was news to us.  Now he is in his final days, it appears, and I will likely not have the opportunity to see him alive again.  I can only rest on the good memories of the visits I have had in recent weeks.  I keep praying for him, especially for God to communicate to him even in the comatose state.  God can communicate through any situation and coma does not keep Him away from His children.  Dad spent a lot of time in the recent years sitting in the nursing home reading God’s Word over and over.  He had worked through the Bible more than a couple times and enjoyed talking about what he was learning.  I feel confident that once Dad leaves this earth he will be dancing in glory in the presence of God. 

Father, thank You for the good day in the clinic.  We have seen several people and have set plans to help them in many ways.  Thank You for allowing us to be extensions of Your healing power to help these people who are suffering.  I pray for wisdom in dealing with each of these patients correctly and doing what is needed for them.  Thank You, Lord, for empowering me to serve You in this capacity.  I pray for Dad, Lord.  Please comfort him.  Wrap Your arms of love tightly around him and make that known to him.  Please forgive him of any sins that would keep any distance between You and him.  Lord, wash him white as snow and bring him home with You.  That is a transition he has looked forward to for so many years.  Please grant him that privilege.  Father, please give Phyllis an extra measure of love.  I love her so much and am so thankful You brought us together 43 years ago.  Please hold her close to You and protect her while I am away.  Lord, I pray for my brother and sister who likewise are concerned about Dad.  Please comfort them at this time.  Thank You, Lord, for Your boundless love.  Amen.

This afternoon included Kid’s Club.  I took a quick break and went over to the ministry building to see a hundred or more kids all involved in some activities.  Steven and Nyletta were there helping.  Damarys took my camera and got some pictures while Jane and I continued seeing patients.  I talked with Steven and he was having a good time interacting with the kids.  This is a special outreach of Jane’s team and the multiple lives impacted by the efforts of Angelita and Maria Luisa are uncountable.  They will be given a special crown in heaven for their tireless work in reaching children and the people of this community for Christ.  Not only does Jane enable medical and surgical care to be delivered here, she enables others to come along side and bring spiritual healing to so many.  God is truly blessing this ministry.

This has been a long day of seeing patients and discussing and planning surgery.  Our schedule has not been as packed as before on previous trips largely because Jane screened all these people ahead of time, had a lot of their workup already completed and had kept out those who were just coming in for a pap smear.  In the past we had the nonsurgical patients mixing in with the surgical patients and this required working through 70 to 100 patients to build the surgical schedule.  At this time Jane had already found the surgical problems and brought those people in only for my evaluation and recommendation.  Now that we have the schedule full, we will not be seeing any more patients in the clinic and will start our surgery week on Monday.  Our anesthesiologist, Paul, is an American who is coming from Shell south of Quito.  Shell is an HCJB hospital and Paul works there as a missionary.  He is coming to support Jane and provide our anesthesia for the week. 

8:15 PM.  We have finished our dinner and now are relaxing and soon will be heading to bed.  The noise of the traffic outside, the barking of the dogs and even the occasional rooster punctuate the night as I listen to all this activity while I am writing this.  People may sleep at night here but other critters keep the night alive with sound.  With the fan running in the room providing ventilation and white noise, I am able to drift off to a deep enough sleep that I don’t even notice the night sounds anymore.  I did learn through some email that my dad continues in a comatose state with no major changes.  I am becoming more convinced he had a major stroke more than end stages of leukemia.  No other details have been forwarded on to me so I am still not sure.  He certainly will not exist for a long time if he is getting minimal supportive care.  I know he has been ready to go to be with the Lord for a long time and his wish is finally going to happen.  He has been in the nursing home for the past few years after having a stroke.  He has not been able to move well at all but has remained mentally sharp and can carry on a good conversation.  His memory has faded a lot but that doesn’t detract from the conversation and his sense of humor.  He is 90, soon to be 91, and has lived a full life.  I can only hope he won’t suffer much longer.

Father, thank You for this good day.  Thank You for giving Jane and me the wisdom and skills needed to accurately assess the problems of our patients.  Thank You for working out the surgery schedule and giving us a productive week ahead.  Thank You for the sheer opportunity to serve You here, to be Your hands, to flash Your smile, to share Your love.  Father, I pray for a good night’s rest for all of us.  I pray we can accomplish good work tomorrow as we help organize all the supplies for the clinic.  I pray for another example that defines another facet of the relationship You wish to have with each of us.  Thank You, Father, for Your unfailing love.  Amen.

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