6-17-2014 (Tuesday)
6 am. The city is alive and has been so for some time. Our house is close to the road and trucks and buses are going by almost continuously. They shift their gears in front of the clinic and create a lot of noise that takes some getting used to. Howard said the people don’t get much sleep here in that things were noisy to about 3 am and then began again about 5.
We made breakfast for the three of us before meeting Jane. Jane meets with her team at 8 am for devotions. Howard and Jordan immediately went to work cleaning out the bodega as the workmen were here putting up the walls on the second floor. I had made some oatmeal for each of us and had nothing to add to it. So we ate oatmeal without any additives. After Howard ate his he commented on how good the oatmeal was. He looked at Jordan and asked, “What have you learned today?” Jordan sat there thinking and then stated with authority, “Oatmeal tastes better with sugar.” We had a good laugh and Howard commended him for phrasing his answer in a positive manner.
Our devotions centered on Ephesians 2:1-13 focusing on the incredible amount of grace God has given to each of us for it is only by His grace that we have any hope and future. We cannot earn heaven on our own. It is only through the infinite grace of our loving Heavenly Father.
Jane and I then went to the consultorio (her office) to see patients.
Clinic:
- I.R. 38 y/o with history of multiple fibroids. Has not been able to conceive. Previous myomectomy at local hospital. General health ok but was advised to obtain echocardiogram because of hypertension. Exam: Uterus enlarged to 16 weeks size, grossly irregular, nodular, not tender, mobile. Biman: Multiple myomas of varying sizes, some 2 to 3 cm in diameter located in upper uterus as well as in the lower parauterine and paracervical areas and posteriorly. Discussed findings and options with patient. She has resigned to the fact that myomectomies would probably not help in the long run and now wants to proceed with hysterectomy. Will schedule echocardiogram prior to TAH.
- These problems are difficult decisions, especially for the patient. On one hand the lady wants to conceive. She has never been pregnant and desparately wants a child of her own. On the other hand she has a problem that makes pregnancy almost impossible. The problem will only get worse and could potentially cause other health issues down the road. It is hard as a physician to recommend a surgery if the procedure won’t really help the patient in the long run. The only option to manage the myomas is hysterectomy. The patient has accepted this and today presents with an attitude of resignation and acceptance that her chances of pregnancy are nil.
- G.G. age 50. Had a hysterectomy by Jane in 2006. Recently had some spotting with urination. Exam by Jane revealed an area around the urethral meatus that had polypoid tissue that was fragile and bleeds touch. Exam today shows a ring of fine polypoid tissue part way around the meatus from about 8:00 to 2:00. This tissue arises from the junction of the exterior squamous epithelium and the urethral epithelium. We discussed this with patient and will proceed with local excision of the polypoid tissue. She will wear a catheter for about a week after the surgery. This tissue does not appear malignant but will send it for a pathology evaluation just to be sure.
- L.T., age 58, with history of vaginal bulge that needs to be pushed back in to be able to urinate. She does not describe stress incontinence. She saw a gynecologist in the past who told her she needed a hysterectomy and vaginal repair. She also has a hernia in the appendectomy incision. She recently underwent a cardiac evaluation and has received clearance for surgery. Exam reveals a hernia in the appendectomy site. She also has a prominent cystocoele that bulges outside with valsalva. The uterus is small and descends to the introitus with valsalva. The urethra is well supported. We discussed the findings with the patient and recommend vaginal hysterectomy and anterior repair. Jane will also fix the incisional hernia.
- E.P., age 67, with history of a vaginal bulge that becomes symptomatic and bothersome. She does not have any problem with bladder function. There has been no bleeding. Gyn history is negative. Exam reveals a prominent cystocoele without uterine descensus. The urethra is well supported. Advised an anterior repair to manage this.
- M.C., age 30, with history of uterine fibroids. In 2009 I helped Jane with a myomectomy procedure. She now presents with more fibroid changes. She has a lot of pain and heavy flow with her menses. In 2009 she had difficulty with heavy painful menses. Now she requires injectable pain control during menses. Her flows are fairly heavy. She wants to have a hysterectomy to manage the bleeding, fibroids and pain. On exam she has a significantly enlarged uterus that is very tender to palpation. We will proceed with a hysterectomy.
- M.C., age 42, 13 pregnancies with one miscarriage. Has history of very heavy menses requiring hormonal management. She remains anemic somewhat. Ultrasound shows large uterine myoma about 7 cm in diameter. Exam shows a significantly enlarged uterus about the size of a 16 week pregnancy. She is bleeding even on the hormonal management. Our recommendation is hysterectomy.
- This lady was so thankful that we would see her and she brought to us a gift of papaya and coconuts. This represents her giving out of her poverty to benefit us. Muchas gracias!!
- M.B., age 37, with very heavy bleeding that has not been well controlled with hormonal management. She wants a hysterectomy but has not had a high enough blood count to proceed safely. Jane has had her on iron therapy and today she comes in with a hemaglobin of 11.3. We will now proceed with the surgery.
- C.M., age 28, with history of infrequent menses, every 3 months, and pelvic pain. She has not been seen before at the clinic. She brought in with her an ultrasound that showed a fibroid and possibly enlarged, polycystic ovaries. Her exam was normal. I suspect she does not ovulate regularly and she would be a good candidate for ovulation induction with Clomid. Jane will treat her with Provera to start a cycle and then try Clomid for a few months.
- M.M., age 18 months, has a cystic mass protruding from the vagina. Jane had seen this some months ago and took pictures and emailed them to me. At that time it appeared to be a simple inclusion cyst. We felt it was best to observe and not try to intervene. The surgery, even an exam, would be quite traumatic at this age and if there is no reason to be more aggressive we felt it was best to observe. She came in so I could see this again. Today the cyst appears unchanged and is a small inclusion cyst that appears attached at the vaginal introitus just behind the hymen. Again, I felt it is best to observe.
- L.E., age 62, presented to a local hospital in April with difficulty urinating. A foley catheter was placed. She has had a 15 year history of vaginal tissue prolapsing out the vagina. Five normal pregnancies in past. General health ok. A recent ultrasound shows a cystic right ovarian mass with some mixed echogenicity. The mass wall is thick and smooth. Exam reveals a large cystocoele and uterine prolapse. There is a smooth, mobile, firm mass involving the right ovary. The left side is not palpable. The rectovaginal septum is well supported with no rectocoele. Our plan is to approach this abdominally with a hysterectomy and bilateral oophorectomy and then a Burch urethropexy followed by an anterior repair if needed.
We are at the end of our schedule for today. Jane said one more patient was downstairs for a dressing change. She showed me pictures of this lady’s feet which are severely, I mean severely, deformed from scarring and contractures from burns from hot oil that spilled on her when she was an infant. Her left foot is so deformed that she walks only on the heel. The right foot angles up with none of the toes or ball of the foot touch the ground. She cannot wear shoes and she said her hope and wish is to be able to one day wear shoes. Such a simple thing that we all take for granted yet this poor lady has lived with this deformity for over 20 years and dreams of the day that she could wear shoes. Dr. Goeff Randolph, plastic surgeon from Fort Wayne, IN, was here last month and did some surgery to help release the scars and allow her feet to start reforming toward normal. Today she can stand on her right foot and have the ball of the foot and some of her toes touch the ground. Her left foot has a long way to go but this, too, is much better than what it was before surgery. One day she will have her dream fulfilled; she will finally be able to wear shoes. I have a lump in my throat just writing this.
Father, thank You for equipping Your servants like Dr. Randolph and Jane to be able to reach out and touch with Your healing touch to this lady. Thank You for empowering them to be Jesus to her. Amen.
Periodically I was able to look out the window and observe Jordan and Howard at work. They have cleaned out the room and already have put down several tiles. Howard taught Jordan how to cut the tile and Jordan has been busy cutting tile while Howard is working on the tile installation. They mixed up a large bucket of cement and the tile install appears to be moving along quite well.
Our Florida church, Englewood United Methodist Church, has supported this ministry by sending some funds to help cover the costs of those patients who have no money and cannot otherwise afford any medical care. M.C. is one patient who will benefit from this fund making it possible to give her the care she needs.
5:00 pm. Howard and Jordan have tiled about half of the floor space in the first room today. They have made remarkable progress. We are now going to get ready to go downtown for dinner tonight. This has truly been a remarkable day.
Father, thank You for giving us this day of work and service. Thank You for allowing Howard and Jordan to come with me and help Jane. Thank You for allowing me to come here and help extend medical care to several people. Lord, when we walk with You and serve You we have the distinct privilege of being Your hands in touching others. We get to bring a cup of cold water to a thirsty soul. We get to sweat and work hard to make facilities better to allow more opportunities for serving others. We get to even see the miracle of watching the lame walk and even be able to wear shoes for the first time. What a joy serving You, Lord. Thank You!! Amen.
Our dinner tonight was at a local eatery that serves great grilled pork chops or chicken. The place would not pass the US Board of Health inspections but we are not in the US and thus we abide by the local Ecuadorian customs. So we indulged in some San Lorenzo culture and had some delicious grilled pork chops, rice and beans. The bill, including Coke, for all of us was $19. Jordan said it was the best meal ever.
“The best meal ever!”
Our cook in her kitchen on the sidewalk.
Before we went to the eatery we strolled along the pier and took in a breathtaking sunset. To me this was a good way to end the day with God making Himself visible in this sunset.
The spectacular sunset.
Father, the sunset was simply breathtaking. The food was delicious. The people were gracious and friendly. All this was provided by You. Thank You! I pray for a good night’s rest so we can be refreshed and ready to work for You tomorrow. Thank You, Lord, for a great day!! Amen.
Medical Missions 
Your dinner sounded wonderful, also the sunset.
It’s wonderful to be able to hear of your work there. Thank you.