9-10-2010 (Friday)
Friday morning began before the sun was up. For awhile the trucks and traffic noise stopped and in the middle of the night all was quiet. Then, a short time later, came the noises of loud diesel trucks shifting and making a lot of noise. There is a speed bump in the road in front of the clinic. It is a sizeable bump that you must slow down for. Thus all the busses and trucks come almost to a halt with their brakes squealing and then all the shifting and engine noise starts back up. This is only about 100 feet away from the ever open windows. The windows in the house are screened and have bars over them but that’s all. No glass to shut out the noise or the dust and dirt. I remember from previous trips that one gets used to the noises and then can sleep through them. Not this morning, however!
I have eaten breakfast and am ready to head over to the clinic for our morning devotions and then to start seeing patients. Jane thought there were about 20 people on the schedule. She said that could mean we would see possibly 30. People hear that the clinic is in session and suddenly they appear on the doorstep. So we expect to have some more names added on to the day’s schedule. From today’s clinic we should complete our surgery schedule for next week.
Father, thank You for the restful night, in spite of the trucks and other noises that interrupted my sleep. I still feel rested and refreshed. I pray for today, Father. Fill us with Your wisdom and grace so we may be equipped to deal with the problems and questions we will face today. Give us insight and discernment to make the right decisions. Above all else, Father, fill us with the ability to represent You in all circumstances and to honor You in everything we do and say. Thank You, Lord, for this privilege of serving You. Thank You, Lord! Amen.
We began our day with devotions. The clinic team met in a room to encourage one another with God’s words to us. Our focus was Psalms 119:9-16. “How can a young man keep his way pure? By living according to your word. I seek you with all my heart; do not let me stray away from your commands. I have hidden your word in my heart that I might not sin against you. Praise be to you, O Lord; teach me your decrees. With my lips I recount all the laws that come from your mouth. I rejoice in following your statutes as one rejoices in great riches. I meditate on your precepts and consider your ways. I delight in your decrees; I will not neglect your word.” As we talked about these verses we focused on hiding God’s Word in our hearts. How do we do that besides rote memorization? I feel it also involves maintaining that close relationship with Him, sharing each moment with Him, walking every step with Him. The closer I keep myself to God, the more I seem to know Him and learn from Him. His Word seems to automatically hide itself in my heart. I found this devotional and discussion gave me a good start on this time I am here in San Lorenzo. Hiding God’s Word in my heart gives me the foundation and purpose of why I am here. I am walking with Him and going where He takes me. I serve Him as He equips me. I said before that the Lord invited me to walk with Him to San Lorenzo. This passage of scripture makes it even clearer to me of why I am here at this time. Thank You, Lord!!
Jane and I began seeing patients for consultation, exam and consideration for surgery. The room was warm initially but with the window open a nice breeze came in and made the temperature in the room much more comfortable. We filled the surgery schedule and saw today some challenging and faith-demanding situations. What follows is a brief summary of each patient.
1. J.G., age 38, history of abnormal uterine bleeding and a large fibroid. She was told by another physician she needed a hysterectomy. She would really like to have one more pregnancy if at all possible. Losing the uterus at this time of her life would be very difficult for her. We reviewed her ultrasound and performed an exam. She has a large fibroid but it is superficial and removable without disturbing the uterus significantly. It sits in what is called the broad ligament off to the right of the uterus. It measures 7 cm in diameter and is as big as the uterus itself. She also has a small, 2 cm, fibroid on the other side of the uterus and this too is very superficial. Our plan is to perform a myomectomy to remove these fibroids and leave her uterus intact and functional.
2. Y.V., age 29, three pregnancies with three C-sections. Her last pregnancy was traumatic in that her baby died just before birth. A tubal ligation was performed at the time of that C-section. This was 10 years ago. She now wants the sterilization reversed if possible as she would really like to conceive. After talking to her about the procedure and warning her that it might not work, she wanted to proceed with scheduling of the tubal reversal, called tubal reanastamosis, procedure.
3. T.S., age 31, has had 5 pregnancies and a tubal ligation at the last pregnancy which was delivered by C-section. She now has a new husband who is pressuring her to have the tubal sterilization reversed. This lady is quite devoted to following the Lord and told Jane that she had a dream about Jane and angels and that a tubal reversal would be successful. It is difficult to understand statements like this in that I would fully believe in what she is saying but also have to make sure some comment like this doesn’t influence me from practicing good medicine.
4. A.M., age 26, has a history of difficulty ovulating for about 6 years. Jane started her on Clomid in July with a good ovulatory response. We told her this was just what should happen and that at the lowest dose of Clomid she responded the first cycle. This was very encouraging. Jane will continue with the Clomid for the next 3 to 6 cycles.
5. L.A., age 64, is a sick man. He had a recent episode of severe right upper abdominal pain and was found on workup to have gall stones and obstruction of the common bile duct. Also found on ultrasound is an Ascaris worm in the bile duct. He was treated for the worm; however, it failed to move out of the duct. His liver function is deteriorating and he is jaundiced from the obstruction of the bile drainage. He also is anemic. Jane plans to operate on him to remove the gall bladder and explore and open the common bile duct. We will remove the worm and the stones.
6. M.A., age 51, has multiple fibroids of the uterus associated with very heavy bleeding and secondary anemia. She is also significantly hypertensive with a blood pressure today of 192/134. Her hemoglobin was 8.4 last month and with iron therapy was 11.4 today. Jane gave her more medication for the blood pressure and we will proceed with a hysterectomy if the blood pressure is better. She initially did not get the second blood count because she had no money. Frequently, these people are penniless and even a simple hemoglobin test is outside their ability to pay. It is hard to deal with how a person’s economic status causes a major roadblock in the ability to obtain health care here. Back home a person gets quality health care regardless. That is assumed to be a right and not a privilege, although that mantra is not written anywhere officially. Yet, here in Ecuador if you can’t pay, you receive no care. It doesn’t really matter what the problem is. It could be life threatening and very serious but if you can’t pay, you go nowhere.
7. D.M., age 85, has a large vaginal bulge that on exam is a large cystocoele and rectocoele. The bladder and bowel are collapsing into the vaginal space and now protruding out causing her a lot of discomfort with sitting. She says the large bulge blocks her urine and she has to push the bulge back in so she can empty her bladder. On exam I also found part of the problem is the uterus is prolapsing down as well although not nearly to the extent of the vaginal bulge. At her age I would like to just correct the bulge problem and not place her at increased risk by adding a hysterectomy if at all possible. We have scheduled her for repairs of the bladder and rectal bulges and add a vaginal hysterectomy if it appears this will cause more trouble in the future if we don’t attend to it.
8. M.L, age 48, has seen Jane recently for a large abdominal mass. Jane found the mass to be a huge, and I mean huge, spleen. The spleen usually is not palpable and it sits tucked up under the left rib cage. Only when it is enlarged does it become palpable. This lady’s spleen extends down to her pelvic bones and fills the abdomen with a huge mass. Jane obtained a blood count and it returned showing an acute leukemia. Today she came in hoping to be scheduled for surgery to remove the spleen. Instead we had to give her the horrible news of her condition. There was really nothing that we could do to help her. She is so poor she could not even afford the ultrasound and labs so the clinic covered those costs for her. Watching her cry and realize through her tears that her life was coming to an end was very difficult. Where does compassion take you on situations like this? How far do you let it pull you along without stepping over the line and doing something wrong for someone? While Jane and Angelita were talking with this lady and giving her all the bad news, I was praying for her. After she left Jane told me she and Angelita were presenting the Gospel to her. Father, please comfort this woman in her distress and anguish. She has a terrible situation and her life will end soon. She seems to have no hope and no help. Please wrap Your loving arms around her and love her in a special way. I pray especially for her spiritual health and the healing she can receive directly from You. Lord, if it be Your will, please heal her, both physically and spiritually. Thank You, Father. Amen.
9. B.B., age 49, is special to me. This is Beatriz whom I operated in 2004 to try to save her from bleeding to death from a vicious cervical cancer that filled her vagina and was bleeding very bad. She had advanced cancer and Jane and I did a hysterectomy just to remove the cancer so she wouldn’t bleed to death. We did not do what would be considered a full cancer removing surgery at the time. She healed up very quickly and gave me a tremendous bonus last year when she showed up at the clinic to visit a post-op patient. She was 5 years out from our surgery and allowed me to examine her. I found no evidence of any cancer and was thrilled for her. In medical practice seeing this type of follow-up is very rewarding to me. One has living proof that God answered our prayers back in 2004 and before me stands a sheer miracle. Beatriz is now 6 years out and has been having some right pelvic pain and thin, ribbon-like stools. Her exam again reveals nothing suggestive of recurrent cancer and a vague, tender fullness in the right lower abdomen. Jane and I wonder if this is a result of adhesions with multiple loops of bowel involved. We plan to look with the laparoscope and then proceed with a laparotomy to deal with what we find. Again, I am praying for Beatriz. Father, please oversee what we are doing with Beatriz. She has been given 6 years of cancer-free life from You and I pray she can continue in that mode for some time. Thank You, Father. Amen.
Just before the next patient Sandra called to inform Jane she was having more signs of labor. She was having regular contractions every 30 minutes and passed a bunch of mucous today. She is obviously getting ready to give birth. We told her to come in when the contractions are 10 to 15 minutes apart. It seemed strange to me, and ironic, that on the heels of the difficult situation with a woman learning she was dying of leukemia, another patient calls about the process of new life.
10. A.T., age 50, had a hysterectomy 4 years ago for carcinoma-in-situ of the cervix. I had helped Jane do this surgery here at San Lorenzo. Now she is complaining of urinary incontinence when she coughs or sneezes. She is a Chachi Indian and we saw her when I took the river trip to Zapallo Grande. She has a problem where her bladder is dropping and our plan is to do a bladder repair.
11. G.P., age 55, came in as a new patient to Jane. She recently had a Pap smear return as cancer of the cervix. She has had intermittent vaginal bleeding for the past year even though she went through menopause a few years ago. On exam I found she had a cervical cancer that had grown through the left side of the cervix into the vaginal lining. However, this seemed to be the extent of the growth that I could feel. This would likely place her as Stage IIa. We talked with her about her options, a surgical approach with a radical hysterectomy or radiation. We discussed going to the cancer hospital and she stated she had no confidence in them. She said she was there 3 months ago with the bad Pap smear results and was told that she had nothing wrong with her and she had no cancer. Some friends told her to come to San Lorenzo because “there are good doctors there who will take care of her.” I feel she could possibly be treated with aggressive surgery but do we attempt that here? She would like to stay here if at all possible. She is thin and in good physical condition otherwise. Jane and I discussed what we could do working together with our cumulative experience and we decided to proceed with an exam under anesthesia and then determine if a radical hysterectomy is the right direction. If not, we will obtain a good biopsy and then refer her to the cancer hospital with proof she has cervical cancer and needs appropriate treatment. Why does a patient receive such poor care at the only place in the country that gives the most hope in situations like this? This question bugged me. And then when Jane and I discussed what we might do, I then tried to discern the difference between faith and foolishness. I prayed about this situation as Jane was talking to the patient and I felt a distinct message that God was telling me to trust Him in this. God says, “Trust Me,” and my experience and training says “You’re foolish if you proceed with surgery.” Then I remember Beatriz back in 2004 when the same pressure was there. Father, I do trust You. I can say that easily but it is much harder to live that. Yet, I wish to make it clear that I do trust You. I feel You are telling me to work with this lady and allow You to cover our hands and guide us through the surgery. Lord, Thank You for this reassurance when it seems we have so little to offer. Paul learned that when he was weak, then he was strong because he was completely dependent on Your miraculous grace. Shower us and this lady with that grace, please. Thank You, Father. Amen.
12. & 13. This couple came in for infertility evaluation. They have been married for 4 years and have been trying to conceive for three. They have gone through a good workup so far with the only finding of irregular menstrual cycles for the past 2 years. In reviewing all the tests including a semen analysis, I felt this lady was likely ovulating infrequently. She does have ovulatory cycles but not every month. We will start her on a cycle of Clomid to induce more consistent ovulation and see if this resolves the apparent problem. Jane will follow up in 3 months and then do more evaluation if needed.
14. G.S., age 62, had a hysterectomy 4 years ago and now has a large vaginal bulge. She has no bladder or bowel problems. Her exam reveals the prolapse changes resulting in lax vaginal support and a large cystocoele (bladder bulge) and a moderate rectocoele (rectal bulge). Our plan is to perform an anterior and posterior repair to restore the anatomy of the vaginal support.
15. A.J., age 64, is another patient I operated on in 2004 on my first trip here. She had a hysterectomy and Burch urethropexy and posterior repair then. Now she has a vaginal bulge that occurred over the past few months. On exam she has a breakdown of the fascial support that bridges between the vagina and the rectum. This allows the rectum to bulge into the vagina. The vaginal tissue was so thin you could see the rectum through it. We will do a posterior repair and put in extra support on the fascia to keep it intact.
16. A.C., age 37, had a tubal ligation 5 to 6 years ago. She wants to conceive again and would like a tubal reversal procedure to accomplish this. Her health is good and we discussed all the aspects of this surgery and she wishes to proceed. She will be our third tubal reanastomosis procedure. We have them all scheduled for next Friday.
17. A.C., age 64, was seen by Jane a few weeks ago for postmenopausal bleeding. I remember talking to Jane via Skype about this lady and I advised Jane to do a D&C to make sure what was happening with the endometrium. Jane spent some time today trying to track down the path report and talked with the pathologist in Quito directly about it. The report showed hyperplasia (overgrowth) and atypia. The atypical changes are a precursor to endometrial cancer. I recommended a hysterectomy. She would like to wait until February to have this done because of family situations at this time. Jane will follow up with her and do the surgery in February.
Our surgery schedule: (24 patients) • Monday: 3 hysterectomies, 1 hernia repair • Tuesday: laparoscopic cholecystectomy, hysterectomy, myomectomy, and hydrocoele repair • Wednesday: bile duct exploration and cholecystectomy, hysterectomy, anterior repair, laparoscope and possible laparotomy • Thursday: 2 hysterectomies, anterior repair, anterior/posterior repair with possible vaginal hysterectomy • Friday: 3 tubal reanastomoses, posterior repair, rectal biopsy and inguinal node removal, destruction of vaginal condylomata, vasectomy and a lipoma removal.
About mid afternoon the kids club met on the front porch of the clinic building. A fair number of neighborhood children had gathered to play games, learn Bible verses and other activities all under the direction of Maria Luisa and Angelita. I went out and took a few pictures. These two women put their heart and soul into sharing the love of Christ to others, especially children. On their own they organized the kids club and meet a couple times a month with the neighborhood children. They have developed a neat ministry to children. Because of the influence of these two ladies who knows if one or more of these children might grow up to be in full-time service to God? I’m certain these two ladies will hear the words, “Well done, thou good and faithful servant,” when they step on Heaven’s shore. Thank You, Lord, for Angelita and Maria Luisa. They show their love for You through their faithful service in reaching out to the many people who access the clinic and to the children. Please give them a special measure of Your love tonight. Thank You, Lord. Amen.
We worked through lunch and realized about 4 that we missed lunch. We then sent Gonzalo on a food run and all of us sat down for lunch/dinner at 5. The food was tasty and filled me up quickly. During dinner Angelita contacted Sandra to get an update on her condition. She is having contractions every 15 to 30 minutes and is leaking more fluid. I talked with Jane about this and we will ask Sandra to come in to the clinic so I can evaluate her. We will probably keep her here and probably will be delivering a baby tonight or tomorrow. My memory bank is pulling up all sorts of deposits from my obstetrical years! I never thought I would be delivering a baby after so many years of not practicing obstetrics and now being retired fully. Actually, I am somewhat excited about the possibility. Lord, please watch over Sandra and help me keep the right perspective on this situation. We aren’t equipped for obstetrics here and if the baby has problems, we will be in a bind. Lord, I am depending on You totally here. Again, I trust You, Lord. Amen.
6:45 PM. Sandra arrived and is having mild contractions every 15 minutes or so. She is not uncomfortable. She says she is leaking more fluid. Just as I was ready to examine her the lights went out. We had one of the infamous San Lorenzo power outages. In a windowless room when it was dark outside as well, the room was totally black. We couldn’t see a thing. We had to wait for a few minutes till Gonzalo turned on the generator. On exam she has moved to about 5 cm but still has bulging bag of water before the head. I didn’t see much fluid leakage. At this point she is still in prelabor but could progress quickly. Her last baby delivered in 3 hours. She will go back home for now but will keep us in touch. I anticipate she will probably do something in the middle of the night. After all it seems all babies prefer to come into the world somewhere between midnight and 6 AM. The power was out for about 15 to 30 minutes before the lights came on in the neighborhood. Jane then shut down the generator. It is a diesel generator that makes horrible noise and it sits right outside my bedroom window. I certainly did not look forward to going to sleep with that thing running in the night. I will keep my flashlight with me for sure, especially if Sandra comes in and we have no power.
8:15 PM. I am finishing my day with some reading before heading to bed. I don’t know whether sleep will be interrupted by a call from the labor room or not. If Sandra doesn’t deliver tonight, she will probably do so sometime tomorrow. We gave a prescription to her husband to go to the Farmacia (pharmacy) to obtain a couple vial of Pitocin to have available at the time of delivery. Pitocin is used to make the uterus tighten down after it is evacuated. This helps stem any excessive bleeding that could occur at that time. Also, if Sandra breaks her water and does nothing, I can use the Pitocin to stimulate her labor some so she can make good progress and not run the risk of prolonged ruptured membranes and getting an infection going. I told Sandra and Angelita about my experience in the Navy when I delivered a patient who had so expected a girl that she already had the nursery decorated in pink and had all girl clothes for the baby. Then out comes a boy and she was totally shocked. She went on and on about having a boy and wasn’t prepared at all for a boy. She said she didn’t even have a name for the boy. So, while I was taking care of the post delivery repair and delivering the placenta, I jokingly suggested she name her boy, Marvin. At that she loudly exclaimed, “Marvin! That’s a horrible name. I wouldn’t even name my dog, Marvin!!” I was glad I had a mask on because I could not contain my laughter. My nurse was doubled over. This patient went on and on about how terrible the name Marvin was. To her I was either Dr. Eastlund or LCDR Eastlund. She didn’t know my first name. So when I signed her birth certificate, I wrote LCDR Marvin Eastlund, MD. I don’t think Marvin will be utilized for a boy’s name here in San Lorenzo!!
Medical Missions 
Whew….that is some update dad! You have a busy week ahead of you. Lots of prayers coming from Jacksonville. Looking forward to more updates! Just pre-warn us in the blog part if the pictures are graphic. 🙂 Love you!
Darc
Wow! Hope you find something to do in your spare time!!!!
Thanks for the update–what a day!! Thanks for the devotional thoughts, too–the reminder to hide the Word in my heart.
Blessings.