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6-18-2014 (Wednesday)

5:30 am.  I slept good in spite of mosquitos landing and feeding, doing touch and go procedures that would awaken me very briefly.  I awoke rested and refreshed and as I lay in bed for awhile thinking and praying my mind kept circling back to that young lady who came in yesterday afternoon to have her dressings changed on her feet.  This young woman had a smile from ear to ear and seemed so thankful for what most of us would consider minimal progress.  I don’t think I’ll ever forget the smile on her face when Jane took off the dressing on her right foot and had her stand on that foot.  Possibly for the first time in this woman’s memory she felt her heel and the ball of her foot touch the floor simultaneously.  The absolute delight that shone on her face was incredible.  She was so excited to be able to experience this.  Her scars were so contracted that the toes and front part of her foot were permanently turned upward pointing toward her knee.  When she would bear weight on that foot all that could touch the ground was her heel.  Now she for the first time felt her whole foot touch all at once.  The smile that erupted was amazing and the hope she felt that one day, maybe soon, she would actually be able to wear a shoe on that foot.  That scene kept replaying in my mind and I found myself praying intensely for her.  Oh how I would love to see her wear shoes!

I think of the many times in Scripture where Jesus healed the lame and people who couldn’t walk actually got up and walked.  The man at the pool who lay there for so long and couldn’t walk.  With just the word being spoken Jesus healed him and he got up and rolled up his mat and walked!  Danced even!  Imagine!  The transition from something possibly even worse than what I witnessed yesterday afternoon to complete healing just amazes me, in fact, blows my mind.  Just picture that scene in your mind…going from being a cripple with deformed feet and legs to being restored whole…in an instant even!  This woman we saw yesterday is receiving healing but the process is not instant like we would like.  Yet, it is happening.  What a thrill for me to just be able to see this and see Jane and Geoff Randolph be Jesus to this woman whose crippled feet will someday be restored so she can wear shoes

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Father, my mind and my heart goes out to You right now as I remember this young lady with feet so badly deformed that she can only walk on her heels.  She longs to be able to wear shoes.  And she is closer to that reality now because of Your grace given to her through empowering Geoff and Jane to help her.  Lord, I pray for her.  I pray for her soul and that she has placed her trust in You.  I pray for her healing.  Please restore her so she can wear shoes for the first time in her life.  Lord, the smile on her face and the hope that exuded from that smile impacted me deeply.  What a joy it must be to You when You see physical needs met, deformities corrected to normal, and lives transformed.  What a joy it must be to be able to do that and offer people hope and joy.  This is a measure of Your incredible grace, Lord.  Only through You could this be possible.  Thank You, Father, for allowing me the opportunity to witness Your grace being extended to this young woman bringing her closer to the time she can wear shoes.  I pray for her right now, Lord.  Love her with a love that exceeds all understanding and heal her.  Thank You, Father.  Amen.

After devotions Jane and I met in the clinic to start seeing patients.

  1. F.E., male age 65, comes from Borbon with a complaint of the “bladder is dropping.”  We were not sure what this meant in a man but he describes leakage of urine, especially when straining or lifting and he wears a diaper all the time.  He mentioned he had a sore on his buttocks and was told he had leishmaniasis.  This sore has been there for 2 years.  He has no history of surgery or injury involving the urinary system and no history of prostate problems.  When we examined him we found a large ulcer, approximately 8 cm, overlying the sacrum between the coccyx and anus.  He had no overfull bladder or enlarged prostate.  We were unsure of what his bladder function problem was and empirically will treat him with medication to manage overactive bladder as this problem is just as common in men as in women.  To manage the large ulcerated area will involve full thickness skin grafting.
  2. M.B., age 46, comes in with heavy menses, recurrent fibroids, and significant anemia.  She also complains of stress incontinence.  I last saw her in 2006 when we did a multiple myomectomy on her.  She had post-operative bleeding that concerned us greatly because our anesthesia had left and we were unsure what we would do if we needed to take her back to the operating room.  However, our prayers were answered and she recovered quickly without any more intervention.  She now has a history of very heavy flows and resultant anemia.  She wants to proceed with definitive surgery of hysterectomy for large fibroids and the menorrhagia.  She also has urinary incontinence with stress.  On exam she has large fibroids filling the pelvis and lower abdomen and sitting on the bladder.  She does have some weakness of bladder and urethral support.  Our plan is to transfuse with some blood to move her hemoglobin from 8 to above 10 and then to hysterectomy and Burch urethropexy.
  3. M.R., age 28, has large mass in lower abdomen.  She thought she was pregnant but when the mass did not grow, she then obtained an ultrasound showing a large uterine fibroid.  She wants to keep the uterus but desires to have the myoma removed.  Her exam shows a 12 cm mobile mass projecting off the upper uterus.  This appears to be a single large myoma.  We recommended a myomectomy procedure to conserve the uterus.
  4. P.P., age 58, with recent history of UTI.  She underwent an anterior repair by Jane and me in 2008.  She states she has good bladder control but feels something coming out of vagina.  She recently was treated for a urinary tract infection and states she has lower abdominal pain.  Exam reveals diffuse tenderness in the suprapubic area but no mass.  Pelvic exam shows excellent support of vagina with ridge of scar along the midline where the repair was performed.  This slightly protrudes with valsalva as the distal urethra rotates slightly.  Uterus is small and mobile and adnexae are normal.  There is diffuse pelvic tenderness.  Plan is to treat medically with doxycycline and ibuprofen.
  5. L.H., age 67, has had a history of stress and urge incontinence but this is now better after treatment with oxybutinin.  She presents with pain after urination.  Pain is located in lower and upper abdomen.  Exam reveals some tenderness in abdomen but no specific points of tenderness or mass.  Pelvic reveals a cystocoele with urethral descensus.  Uterus is small and well supported.  Adnexae are not palpable.  Will treat for possible UTI with norfloxin and observe.  Patient does not want surgery now.  Has rash on arms.  Jane will also treat with benadryl.
  6. F.P., age 34, has had 5 pregnancies and previous tubal ligation.  Now in a new marriage and wants her tubes rejoined so she can conceive.  She had a tubal ligation at the time of a cesarean section.  Exam reveals normal findings.  Will proceed with minilap incision to determine if tubal reversal is possible.  If so, will then proceed with bilateral tuboplasty.  Discussed increased risk of ectopic pregnancy.  Patient wants to proceed.
  7. D.Z., age 53, with previous vaginal eversion on which we operated in 2011.  At that time we did a total hysterectomy, Burch urethropexy and posterior repair.  She has had the development of vaginal eversion again with large vaginal sac hanging out.  She states that three weeks after the last surgery she developed a bad cough and had a sudden pain in the suprapubic area.  Following that she noticed a bulge of vaginal tissue coming through the introitus.  This bulge has progressive enlarged over time.  She does not have stress incontinence but some urge if she has a lot of pressure and a full bladder.  She is sexually active.  Exam shows complete vaginal eversion to a bulge of about 10 cm diameter.  The bulge reduces easily and the urethra is fairly well supported.  She has a rectocoele on rectal exam.  Our approach at this point is to redo the Burch urethropexy and paravagial repair or a sacro-spinous fixation to anchor the upper vagina.  Then will do a posterior repair.
    1. This patient is very poor and cannot afford surgery.  The Florida church, EUMC, has graciously donated some funds to help with the care of a couple needy patients.  This lady’s surgery will be covered by some of these funds.
  8. V.C., age 27, has had regular menses up to May when she bled a full month.  She was treated with some medication elsewhere and had stopped only to start spotting again.  Exam last week by Jane was normal.  This is likely an episode of dysfunctional bleeding and the first treatment is to cycle with Provera 10 days a month for three months.  If this does not help, then a D&C would be indicated.

At this point there are no more patients scheduled to be seen today so I think I will capture the moment to lay down and rest my legs a little.  She is going to finish filling in the surgery schedule with general surgery patients she has seen already and was waiting to see what we scheduled for gyn surgeries before adding these patients.  Our surgeries start on Saturday and we will be busy!

My Florida church, EUMC, sent along with me some digital Bibles from Galcom International.  These are little solar powered players on which the entire Bible is recorded.  They are produced in multiple languages.  Of course, I brought Spanish ones.  Jane was so impressed with these units and I told her we wanted to distribute them to people who cannot read.  She said she wanted to show one to her pastor here in San Lorenzo as he has planted several churches in the remote villages in the area and many of these people cannot read.  The pastor came today and we showed him one of these units.  He was so thrilled to see this type of technology and said many of the people who attend these churches are illiterate and these units would allow them to listen to their own copy of the Scripture.  A new project developed as we spoke.  Jane would like to work with Galcom to see if we could acquire several of these digital Bibles to distribute to the people through this pastor.  Who knows how God will work in situations?  I had not thought about bringing these units along until the chair of the missions committee at church mentioned these to me and arranged for Galcom to send me a few.  I received them a few days before coming to San Lorenzo and now it looks like this could be a new opportunity for Galcom to participate in sharing the Scriptures with many people.  Wow!

Jane is handing one of the Galcom digital bibles to her pastor.  I didn't realize Jordan was in the background.

Jane is handing one of the Galcom digital bibles to her pastor. I didn’t realize Jordan was in the background.

Jane had one other patient who came in for a gyn consultation.  She represents some of the more difficult problems to deal with because of the need for medications that can’t always be easily obtained and the need for regular follow-up along with a good understanding on the part of the patient to help manage the situation.  I am talking about the all too frequent, it seems, occurrance of irregular menses and the underlying issue of anovulation.  The pressure in this culture for the women to be fertile and have multiple pregnancies is sometimes great.  When a woman has a difficulty with ovulating regularly, then the stress elevates because conception may not occur.  Many times I sense the patient has minimal understanding of why the problem is occurring or what to do about it.  Sometimes they come in with a diagnosis from some other place that has them convinced they have cysts or some serious disease.  These ladies are desparate to demonstrate they can conceive.  In the US we have several methods of evaluating the ovarian function and multiple medications that will specifically address the problems.  However, here these medications and tests are not readily available and if they are may be too expensive to even be utilized.  Plus, add to this the reality that many of these patients do not live in the immediate area and the physician may not see them again for some time.  To adequately manage anovulation, especially if using ovulation-stimulating medications, the doctor and patient must keep in touch regularly, sometimes monthly.  This becomes a barrier to the delivery of care here at times.  The patient we saw this afternoon was a 20 year old who had had regular cycles and then transitioned to having none at all unless they were induced.  What happens at times are well meaning physicians placing these women on the birth control pill just so they have a regular cycle.  However, the cycle is generated by the pill and the ovary is put to rest.  Take an ovary that is not functioning fully and suppress it with the pill and this ovary may not respond at all later.  This makes the infertility problem even worse.  For this patient I recommended that Jane cycle her with Provera about every 3 months since she does respond to this short dose of progestin.  This keeps the patient from having an unpredictable bleeding episode but also allows time for the ovaries to respond normally.  Sometimes the ovaries will resume ovulation function and then pregnancy can result.

Howard and Jordan have been busy installing tile.  This is a picture of their progress as of lunch today.  Jane is very excited.

Tile installation so far.

Tile installation so far.

 

Our evening meal was another night out on the town.  Well, it was a night out as I am not sure some gringos would do well being out on the town after dark.  We went down to a corner eatery a short distance from the clinic.  Again, the cooking took place on the sidewalk and we ate in a small room that opened to the sidewalk.  There were about 4 or 5 tables.  We had our choices of grilled beef, grilled pork, or grilled chicken.  Then this came with slaw, rice and beans.  The total cost for the four of us was $18.50.  We had a great meal and then came back to the clinic to call it a day.

The best meal ever as of tonight.  And he ate it all plus some of Jane's meal.

The best meal ever as of tonight. And he ate it all plus some of Jane’s meal.

Howard and Jane showing their meals.

Howard and Jane showing their meals.

The heat today was intense and it has sapped us all.  This morning it was so warm and humid my shirt was very wet and all I was doing was sitting in the clinic seeing patients.  Sweat was dripping off my face and arms.  Howard said he got so hot working on the tile that he almost overdid it.  He had to take a break just to cool off.  Even this evening it is still quite warm and muggy.  We are glad we have fans running in our rooms to give us some ventilation.

Tomorrow Jane and I will see a couple more patients but our schedule now is full.  She has several women who wanted to see me to have a tubal reversal procedure.  Now that our schedule is full we won’t be seeing these people.  I am not that comfortable doing these procedures as the risk of a tubal pregnancy is much higher than normal.  In this area where medical care is not immediately available, a ruptured tubal pregnancy could easily cost the woman her life as the internal bleeding can be quite brisk.  I really don’t want to set someone up for a situation like that and we counsel these patients extensively so they understand the risk.  I am glad our schedule is full and we don’t have to consider these requests.  We will do some minor surgeries tomorrow, all under local anesthesia.  Then Friday we will spend the day getting the operating room all ready for our week of surgeries.  Our hope is to have things prepared so the turnover time between cases is much less.  Then Saturday we start our surgery schedule.

Father, thank You for this day.  We saw some people who really need Your healing touch.  Lord, we ask for Your wisdom in dealing with these situations and providing the correct care.  Father, it is a privilege to serve You here.  Certainly, the work is hard and it is hot and muggy making us all uncomfortable; however, the joy of working with You and following You, walking with You, is incredible.  Thank You for giving us the opportunity to be here and serve You through serving the people who come to see us.  Lord, thank You for allowing me to see some patients I have taken care of previously.  Thank You for allowing me to be able to help them again.  Lord, it is so comforting to have a close, personal relationship with You.  Thank You, Lord.  Amen.

 

 

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Comments»

1. Darcy Clawson - June 18, 2014

Tile is looking great! Darc

2. darcy.clawson@gmail.com - June 18, 2014

J looks like he has been his goofy self! I have enjoyed reading the updates and seeing pictures. That is a serious meal! And I can’t believe he ate it all! Tell J to stay hydrated and to keep eating! 🙂 Darc


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