group getting their fantasy football draftFor anyone who is an avid sports fan, this is a great time of year. The baseball pennant races are full-bore, the college football season has kicked off and the 94th season of the National Football League (NFL) begins on Thursday night, September 5, 2013. Six months later, on February 2, 2014, the NFL season will end with the crowning of a champion team of Super Bowl XLVIII.

Between now and February, a curious addiction will befall many otherwise sane men and women who enjoy following professional football. They will be consumed with the stats of players who most likely don’t even play for their favorite teams. They will spend many hours studying obscure facts such as how well a given running back performs on artificial turf versus real grass. They will struggle to juggle all-star lineups to best take advantage of a scoring system that approaches the complexity of the U.S. Tax Code.

Unlike the treatment delivered by the specialists at Texas Back Institute to patients with back pain, herniated discs or other back problems, there is really no cure for this football sickness. These lost souls are smitten by the phenomenon of playing fantasy football!

Consuming Football Facts

It may not surprise you to learn fantasy football is a very big business. It is estimated by the Fantasy Sports Trade Association that 32 million people, aged twelve and older in the U.S. and Canada, play fantasy sports. The trade group notes that fantasy football players make up 90% of the fantasy sports “industry.” This participation has grown by over 60% the last four years with 19% of males in the U.S. playing fantasy sports.

Because of this high level of participation many consumer products companies such as Sprint, Yahoo, ESPN, Fox and others have invested millions of dollars in fantasy football services and promotions. The two groups who usually disagree about almost everything associated with professional football – NFL properties (composed of the team owners) and NFL Players (the players’ union) – have both created products and services that encourage fans to play fantasy football.

The Texas Back Institute Dream Team 

Most of the fun of playing fantasy football involves choosing a “dream team” from a group of outstanding players. There are no bad football players in the NFL. They’re all good. Therefore, getting to choose the best of the best for one’s own team can be great fun.

In a similar fashion, the spine specialists at Texas Back Institute are the best in their class and as such, there are only great choices. In celebration of the hundreds of thousands of fantasy drafts in full-swing at this moment, we thought we’d introduce you to our dream team.

History of the Team:

Texas Back Institute was formed in 1977 by Stephen Hochschuler, M.D., Ralph Rashbaum, M.D. and Richard Guyer, M.D. The organization is internationally recognized for excellence for spine injuries. In football terms, this team plays offense and defense equally well and the patients are the big winners.

The Texas Back Institute Fantasy Team:

As with NFL teams, the Texas Back Institute team is composed of the best of the best of spine surgery, research and therapy. The game plan for our team has been consistent for more than 35 years. Each patient injury or condition is unique and is best treated with the most minimally invasive approach.

Here’s a brief “draft” report on each of the Texas Back Institute physicians.

arakal0Rajesh G. Arakal, M.D.

Specialties: Orthopedic Spine Surgeon

Add Dr. Arakal and other TBI surgeons to your team if you need thorough evaluation and treatment of cervical, thoracic and lumbar pathology.

Belanger_MD_small

Theodore Belanger, M.D.

Specialties: Orthopedic Spine Surgeon

Add Dr. Belanger and other TBI back experts to your team if you want a spine specialist who evaluates each patient and their situation carefully and makes treatment recommendations based on their goals.

Block_PhD_Small

Andrew R. Block, Ph.D., A.B.P.P.

Specialties: Psychologist

Add Dr. Block to your team if you need to overcome emotional difficulties of surgery, deal with stress and control medications to achieve the best surgical outcomes.

blumenthal

Scott L. Blumenthal, M.D.

Specialties: Orthopedic Spine Surgeon

Add Dr. Blumenthal and other TBI back specialists to your team if you believe the goal of a spine surgeon is to get his patients back to life using the most advanced motion-preserving technologies, including lumbar and cervical artificial discs as well as posterior dynamic stabilization.

bosita

Rey Bosita, M.D., M.B.A.

Specialties: Orthopedic Spine Surgeon

Add Dr. Bosita and other TBI physicians to your team if you want to be treated with respect and have your fears about neck and back pain removed.

bradley

W. Daniel Bradley, M.D.

Specialties: Orthopedic Spine Surgeon

Dr. Bradley along with every other TBI specialist should be on your team if you feel treatment should use the latest in motion preservation and minimally invasive surgical techniques.

cable

James D. Cable, M.D.

Specialties: Occupational & Sports Medicine

Add Dr. Cable to your team for occupational and sports medicine issues. He knows wear and tear eventually affect all of us but most back pain is manageable with proper care.

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Michael F. Duffy, M.D.

Specialties: Orthopedic Spine Surgeon

Add Dr. Duffy to your team if you agree that we should get busy living! His goal and that of the other spine specialists at TBI is to deliver effective spinal care to patients in order for them to return to doing what it is that makes them happy.

gibbs

Sharon J. Gibbs, M.D.

Specialties: Physiatrist

Add Dr. Gibbs to your team if being in pain affects many aspects of your life. As a physiatrist she works hard to provide patients with the best comprehensive non-surgical care.

guyer

Richard D. Guyer, M.D.

Specialties: Orthopedic Spine Surgeon

As one of the founding physicians of Texas Back Institute, Dr. Guyer is both a player and a coach for new team members. Add him to your team if you agree with his “family test” philosophy – treating patients the way he would want his family members to be treated.

Henry_MD_web_1

Shawn M. Henry, D.O.

Specialties: Orthopedic Spine Surgeon

Dr. Henry and the other spine specialists at TBI should be on your team if you want to be treated with the most advanced technology and treatment available for your condition; holding surgery as a last resort.

hisey

Michael S. Hisey, M.D.

Specialties: Orthopedic Spine Surgeon

Add Dr. Hisey to your team if you feel the goal of neck and back treatment is to return patients to productive and pain-free activity using the most advanced minimally invasive and motion-preserving techniques.

hochschuler

Stephen H. Hochschuler, M.D.

Specialties: Orthopedic Spine Surgeon

Add Dr. Hochschuler and the other spine surgeons at Texas Back Institute to your team if you have lumbar spinal problems or have had a failed spinal procedure.

Jehan_85x85_1

Effat Jehan, M.D.

Specialties: Spine Triage Specialist

Add Dr. Jehan and the other specialists at TBI to your team if you feel the goal should be to help treat not only back and neck issues but also to provide effective coordinated support to help patients get through every day of life without any stresses related to their condition.

lankford

Craig Lankford, M.D.

Specialties: Physiatrist

If you want to be treated with respect, compassion, add Dr. Lankford and every other physician at TBI to your team. He can help you understand how pain affects your everyday life in order to help you get back to life.

lieberman

Isador Lieberman, M.D., M.B.A., FRCSC

Specialties: Orthopedic Spine Surgeon

Add Dr. Lieberman and the other spine surgery experts at TBI to you team if you want to be treated as if you were the only patient we have.

marchetti

Jason Marchetti, M.D.

Specialties: Physiatrist

If you believe in ethical treatment and the importance of educating patients regarding all available treatment options, you should consider adding Dr. Marchetti and the other spine specialists at TBI to your team.

patel

Nayan R. Patel, M.D.

Specialties: Physiatrists

Add Dr. Patel to you team if you think patients should be treated in the same way a physician treats his own family.

rashbaum

Ralph F. Rashbaum, M.D.

Specialties: Orthopedic Spine Surgeon, Pain Management

Add Dr. Rashbaum and the other spine surgery specialists at TBI to your team if you want a timely response to back conditions which leads to predictable outcomes.

shellock

Jessica Shellock, M.D.

Specialties: Orthopedic Spine Surgeon

Add Dr. Shellock to you team if you think it’s time to take your life back, with minimally invasive treatment. Along with the other experts on the TBI team, she is highly trained in the latest procedures.

Tolhurst_MD_web

Stephen R. Tolhurst, M.D.

Specialties: Orthopedic Spine Surgeon

If you want a doctor who sees surgery as a last resort and is dedicated to returning you to the lifestyle you had before the back pain, you want Dr. Tolhurst on your team.

zigler

Jack E. Zigler, M.D.

Specialties: Orthopedic Spine Surgeons

Add Dr. Zigler and the other spine surgeons at TBI to your team if think surgery should be the last resort. However, if it’s required, he’s one of the best spine surgeons in the U.S.

Choosing Your Team

There are literally hundreds of ways to set up your league and arrange for a draft of NFL players. The best advice for those new to this pastime is to understand how the players’ performance will be scored each week. This will help determine the number of running backs, wide receivers, tight ends to choose. For example, in some leagues, the yardage gained by running backs is weighted higher than the passing yardage of quarterbacks.

One should also be aware of the “bye” weeks each team has (when they are not playing) because this will mean a player on the team with the bye, will not play that week and should not be in the lineup.  Here’s a good primer  on choosing your fantasy team.

Fortunately, choosing a spine specialist is much easier than choosing a fantasy football team! With more than 35 years of excellence in spine treatments, management of many FDA trials and a foundation of minimally invasive treatment, the dream team of physicians at Texas Back Institute is championship caliber.

DUCK-DYNASTY-facebookYou might say the executives of the A&E cable network were pleased with the premiere of the 2013 season of Duck Dynasty. Actually, it would be more accurate to say they were happy, happy, happy – to borrow a phrase from the patriarch of the Robertson clan!  As USA Today noted, “Wednesday’s episode, which focused on a surprise wedding-vow renewal ceremony for Phil and Kay Robertson, attracted 11.8 million viewers and 6.3 million advertiser-coveted young adults (18-to-49).” This was no fluke. This episode was up 37% in viewers and 26% in young adults vs. last season’s premiere, which also set records.

So, what gives here? Why would almost 12-million viewers tune in to a reality show based on the often ridiculous exploits of a group of self-avowed, redneck duck hunters?

Dr. Ralph F. Rashbaum, M.DWe asked Texas Back Institute surgeon and avid outdoor sportsman Dr. Ralph Rashbaum that question and his response is consistent with media observers around the world, “It’s simple, really. This show is about family values. All of the hunting, fishing, duck calls and related hijinks are just supporting storylines to this.”

Whether it was intentional or not, Duck Dynasty and the Southern charm of the extended Robertson family has had a positive influence on a large number of people –  both city slickers and country bumpkins – who have developed an interest in hunting and fishing. While the fishing rod, shotgun and camouflage apparel manufacturers are (dare we say it) happy, happy, happy, this will inevitably lead to more people in the fields when the fall hunting season kicks off in September.

Unfortunately, some of these hunters will show up in Dr. Rashbaum’s examining room shortly thereafter. Before getting some advice from him about avoiding back injuries while swinging that shotgun, let’s take a moment to introduce Duck Dynasty to precious few who have not made the acquaintance of the Robertson family of West Monroe, Louisiana.

Meet the Folks who Work for Duck Commander

 

The storylines of the 1950’s situation comedy “I Love Lucy” worked around a one-bedroom apartment in New York City where Lucy and Ricky Ricardo managed to get into hysterical predicaments with the help of their neighbors, Fred and Ethyl Mertz. Similarly, almost every episode of Duck Dynasty incorporates the “Duck Commander” duck call factory. Unlike Lucy and Ricky’s home, this factory actually exists and this very successful company, started by Phil Robertson, has produced highly regarded duck calls for many years.

When Phil retired to hunt ducks, fish for crappie and teach his grandbabies “how to avoid becoming yuppies,” his son Willie took over as CEO of Duck Commander. The other Robertson son, Jase, is an employee of the company and, as the most of the funny premises of the show result from Jase refusing to recognize the authority of his older brother, Willie. He is usually joined in this harassment of his brother by their Uncle Si, Phil’s brother, a Vietnam vet, perpetual ice-tea drinker and full time philosopher, and the rest of the employees at Duck Commander.

Each week, these real-life characters deal with simple issues that are cleverly embellished to become a comedic crisis. In the end, everything gets worked out and the last scene of every episode has the entire family around the dinner table with Phil saying grace.

Duck Dynasty: A Boon for Outdoor Sports

The fun these folks on Duck Dynasty are having is resonating with men and women who have decided to take up the sports of hunting and fishing. Several outdoor sports trade publications have noted that the show has done more for increasing the popularity of these ancient pursuits than anything in the past century.

It’s estimated by the National Shooting Sports Foundation (NSSF) that more than 20.6 million people in the U.S. hunt each year and this number will likely increase with the popularity of this show and others like it. Two years ago, the NSSF noted that more than 8,000 U.S. hunters annually were injured while enjoying their time in the woods and as more novice hunters get out in the field, this number will likely increase.

As someone who is both an avid outdoor sportsman and highly-regarded spine surgeon, Dr. Ralph Rashbaum is in a unique position to offer some guidance to both novice and seasoned hunters and anglers. “Stamina and flexibility are the two most important factors in avoiding back strains or injuries, but common sense and proper safety precautions are even more important,” he said.

Hochschuler and Rashbaum 03Dr. Rashbaum continued, “I love to bow hunt and many times this is done from a tree stand to avoid the superior sense of smell enjoyed by deer. Climbing up to the stand can cause back strains if the muscles are not properly conditioned. Falling from a tree stand can seriously injure or facture the vertebrae in the spine. This type of accident is very common and it can be avoided with proper precautions.”

Dove season begins in most states in September and many hunters will be donning the camo and swinging their 12 and 20-guage shotguns for hours. What does Dr. Rashbaum suggest for these hunters to avoid back strains and injuries?

“I’ve been on a 4-day dove hunt in South America, where my son-in-law and I shot more than 2,300 rounds of 12 and 20-gauge shells! Needless to say, we were tired at the end of the day (however, not as tired as the retrievers who brought back the birds!), but because we had conditioned our shoulders, neck and arms and had spent time stretching these muscles before the hunt, we were able to have an amazing experience and very little back pain.”

Fishing is also popular with the Duck Dynasty clan and millions of other outdoor sports enthusiasts. What does Dr. Rashbaum recommend to avoid back strain from a day of casting? “It really depends on the type of fishing you are thinking about. I love to deep-sea fish and also enjoy fly fishing in fresh water. These are two very different experiences and require different conditioning.”

“If you think you might fighting a marlin for two hours on the open sea, you should definitely get to the gym a few weeks before the trip and work on building strength in your back, shoulder and arm muscles. This can be done with weight training as well as such exercises as rowing and pull-downs. On the other hand, the most dangerous part of fly fishing is not from casting but rather from walking on slippery rocks to get near the fish. Having appropriate equipment – waders with boots that don’t slide and using a walking stick – will help with this.”

Life Lessons of Duck Dynasty

It’s interesting that the situations and values portrayed on Duck Dynasty seem to be as relevant to an urban audience as it is to that which is rural. While he lives and practices in the highly-urbanized area, Dr. Rashbaum is a big fan of the show. “The people on Duck Dynasty are the salt of the earth and represent the best of family values. Plus, they’re very funny!”

It appears that life lessons of Phil, his family and friends on Duck Dynasty go beyond frog catching and duck calling. As Uncle Si would say: “That’s a fact, Jack.”

Day 10

We couldn’t believe it was already Saturday. Our last day in the operating room had crept up on us so quickly. We had only one surgery scheduled for today, however if had the potential to be a substantial case.  16 year-old Sheila has spastic cerebral palsy, a neurological disorder caused by injury to the brain in the perinatal period leaving her non-communicative and non-ambulatory. As a result, her body is tightly curled into the fetal position due to the imbalance between her flexor and extensor muscles.  Because of this muscle imbalance, her spine has developed a severe deformity making it near impossible for her mother to provide care and personal hygiene, and rendering her unable to sit up even with a brace or some form of support.  Sheila’s mother carries her daughter draped over her arms. The girl is undernourished, a clear sign that feeding her is difficult. Finally, Sheila is in constant pain as manifest by her heartbreaking wail.

Image 1 Sheila's x-ray Sheila’s x-rays

While Sheila will never regain the use of her muscles, nor will she ever walk, Dr. Lieberman could still use metal screws and wires to reduce the curve in her spine and to allow her to sit upright. This would tremendously reduce her mother’s burden as caregiver. It might also even help with some of Sheila’s pain.

Our morning got off to a good start; we were even ahead of schedule… until Zvi jinxed us by commenting on just that. Within five minutes the entire hospital lost power, delaying our start time. Power returned to the operating rooms within half an hour but the rest of the hospital was still in the dark. The head nurse of the surgical ward even borrowed an outlet in our operating room to boil eggs for her lunch.

image 2 boiling eggs in the OROur operating theatre in Mbarara doubled as a kitchen while power was lost throughout the hospital

Sheila’s operation took almost 5 hours. As Dr. Lieberman revealed the spinous processes of Sheila’s spine (the parts the form the bumps under your skin), he made an unfortunate discovery. Because she is unable to bear weight and likely deficient in vitamin D, Sheila’s bone was very soft.  Worse yet, it wasn’t clear that her soft bone could withstand the pressure of the metal wires even after she had healed. Past the point of no return, Dr. Lieberman finished the surgery and Sheila was sent to the ICU.

Sheila’s case exemplified some of the ethical dilemmas in surgery, and so our lesson of the day revolved around her. Unlike our other cases from this week, Sheila’s operation was not expected to provide significant symptomatic relief. When I asked Dr. Lieberman what the goal of surgery was, he explained that sometimes you have to adopt a perspective that includes the suffering of the patient’s family. In Sheila’s case, her mother was unable to properly care for her in her current state. Perhaps a straighter spine would allow Sheila to prop herself up and eat, thus improving both her and her mother’s quality of life.

Having just completed our last surgery, the team packed up the operating room and stored our equipment for pick-up the next day. After rounding on some of our patients, we left the hospital for our final dinner in Mbarara. We were joined by Dr. Joseph, a surgical trainee at the hospital, and by our trusted middle man, Metu, who takes care of all the shipping and receiving for the mission. Back at the hotel later that evening, the team sat with a bottle of wine and some beers and reflected on a very productive and rewarding week. We shuffled off to bed, each one wishing this had not been our last operating day.

Day 11

Move out day. After a leisurely breakfast at the hotel, Izzy, Zvi, Rob and Dani left for the hospital for a final review of the patients. There they met with Dr. Deo and Dr. Joeseph and as a team changed all the dressings, pulled all the catheters, and provided last minute therapy and discharge instructions.  At the hospital, Rob immediately began retrieving our equipment from storage and loading it with Mr. Metu and his team onto the delivery truck. When all packed, the four made their way back to the hotel to meet up with Sherri and Jen. The six of us then loaded our luggage onto the truck and started the nearly eight hour drive back to Entebbe.

Along the way, we stopped at Lake Mboro National Game Reserve. We spent over two hours driving though the park, taking photos of zebras, warthogs, monkeys, and other indigenous wildlife. It was our first and only tourist experience inside Uganda!

Image 4 Zebras at Lake Mboro Park

Zebras at the Lake Mboro National Park

Image 5 Lake Mboro

Lake Mboro

We made it to Entebbe eight hours later with numb bottoms and empty stomachs. In our usual fashion, we discussed the lessons of the day over dinner at the hotel.

With the long drive back to Entebbe to reflect on my experience on the Mission, I realized I had witnessed some of the best leadership and team building skills I have seen yet. Dr. Lieberman is as natural a leader as they come, and from watching him and his surgical team over the past week, I recognized the skills that make an effective team leader: expertise that commands respect; teaching methods that drive pupils to want to know more; organizational skills and the ability to coordinate a network of moving parts; setting an example of patience and perseverance in the face of challenges and setbacks; encouraging team members to reflect on their own learning and their roles within the team; and finally, the acuity to select members of team that have their own expert skill sets and personality types that mesh together naturally. That was one of the most valuable and translatable lessons I learned during my two weeks with the Uganda Spine Surgery Mission.

So that’s it! Time to sign off. Tomorrow the team flies back to London and then on to our respective home cities. It was a privilege to be part of the 2013 Spine Surgery Mission, and I look forward to hearing about all the successes of the 2014 trip!

Quotes of the day:

“We still have a wottle of bine”

“Six numb bums”

Day 8

Today’s first surgical patient doesn’t have a first name. At least, as far as his medical records at Mbarara are concerned, his first name is C. C is a sixty-five year-old man who is, for all intents and purposes, a wheelchair-bound quadriplegic. Degenerative changes in his cervical spine (his neck) have compressed and damaged the spinal cord, leaving him with paralysis in his legs, a loss of bowel and bladder function, minimal function in his right hand and none in his left that has progressed over three months. Given this clinical picture, I was certainly caught off guard when, while lying flaccid on the operating table awaiting his anesthetic, C asked me whether the operation would allow him to walk again. I passed the question on to Dr. Lieberman anticipating an apologetic response and was astonished to hear that indeed, Dr. Lieberman hoped the operation would accomplish just that.

Similar to Prudence’s operation, Dr. Lieberman approached C’s vertebral column through the side of his neck, navigating around some critical anatomy. He handed me a retractor he was using to push aside a vessel and asked, “What are you holding right now?” “The common carotid,” I replied, referring to the main artery carrying blood to the head. “Correct,” he said, “if you slip, the patient will have a stroke.” Needless to say my hand cramped up a bit while standing there. Unlike most of the operations so far, C’s progressed without any surprises from our hosts (finally, no power outages!) and before we knew it, his decompression (making more room for the spinal cord) and reconstruction (rebuilding and fusing the bones together) was complete.  We were very soon ready for our second patient Ida, who was being walked (yes, walked!) into the OR for her surgery that afternoon.

image 1 Ida walking to OR Ida chose to walk (with some help) to the operating room prior to her surgery

Ida was not a new patient. Dr. Lieberman had operated on her cervical spine (the part in her neck) last year. She now returned with pain, weakness and tingling in her legs caused by spinal stenosis (when the spinal canal is narrowed and compresses the nerves in the cord). Last week, Ida had walked into our clinic slowly and with an unsteady gait, supported by her son who has since not left her side at the hospital for more than 20 minutes to stretch his legs. She wore a kind expression on her face that day that, along with her son’s iconic NY Yankees baseball cap, have made lasting impressions on us. Now, as Ida was assisted onto the surgical bed, I thought about her son who was undoubtedly pacing outside the double doors to the surgical wing, sporting his distinctive cap.

During Ida’s surgery, Dr. Lieberman carved out space around the compressed portions of the spinal cord and secured screws and rods in place to stabilize the spine. The highlight of my week came next, when Dr. Lieberman allowed me to secure a few screws and to help suture the incision. It’s a small thing for a surgeon, but as a medical student it was the first time I would leave my physical mark on a patient. The fact that it was kind-faced Ida who would carry the scars of those stitch marks made it even more meaningful.

Image 2 Ida & fam on private wardIda, her son and niece in the private ward the day after her surgery

The following day, I went to visit Ida and her son in the private surgical wards. Aside from a bit of pain, she was in great shape. As her son walked me out to the corridor, we chatted about their experience throughout his mother’s care. They had tolerated the crowded mini bus system over the 300 kilometer trip from Kampala to see us in Mbarara, only to find themselves completely disoriented and without instruction upon arrival at the hospital. Once admitted (to the private ward, no less), they had to provide their own food, bathing basin and other essentials. There were showers for those in the private ward, but no accommodations for a bed-ridden spine surgery patient. After speaking with Ida’s son, it was clear to me that in Mbarara and perhaps Uganda at large, a patient must be his or her own advocate. Without a middle man to coordinate between patient and doctor, the patient’s own initiative determines the outcome of his or her care. In fact, when it was time for Ida’s surgery, no nurse came to retrieve her. Exasperated, her son walked his mother to the surgical ward and received her stretcher after the operation was complete. The lesson of the day was embedded here: As part of the surgical team, I had a narrow view of our patient’s experience; as far as I knew, she had showed up to our clinic, arrived at the hospital for admission several days prior to surgery, and had made her way to the operating table just as was meant to be. But in between those encounters, Ida and her son had fought to get attention from uninterested nurses and administrators and had navigated a non-intuitive system in their efforts to seek optimal health care.

Day 9

After a surprisingly smooth day yesterday, we had a few curveballs thrown our way today (lest we should get too spoiled with things going as planned!) Our first patient today was Catherine, a 14 year-old girl with a large thoracic kyphosis (an over-pronounced curve in her upper back). Catherine’s condition was consistent with Scheurmann’s disease, a pathology of abnormal bone growth causing wedge-shaped vertebra that exaggerate the normal thoracic kyphosis. With her deformity, Catherine found it painful to carry baskets of food on her head as is common practice here. Dr. Lieberman’s plan was to straighten Catherine’s curve with metal rods anchored to the spine with vertebral screws. There were several power outages throughout the surgery, during which Dr. Lieberman could not use his ultrasonic bone cutter. Nevertheless, he adapted the procedure to the tools that he had until power returned. He would not be derailed by a simple power loss!

Image 3 Catherine Catherine

Image 4 Catherine x-raysCatherine’s x-rays

Our determination to get through the day unscathed met another challenge that afternoon. The autoclave (the machine that sterilizes our equipment between surgeries) failed during its cycle, leaving us potentially still contaminated equipment for the operation. Our second patient, Aguma, who had two level spinal stenosis (narrowing of the spinal canal with compression of the nerves) lay prepped and sleeping on the operating table while Dr. Lieberman, Rob and Sherri brainstormed alternatives. They decided to rerun the sterilization (a 45-minute cycle) while in the meantime proceeding with the operation using alternative tools. Rob scoured the hospital’s sterilized equipment room for substitutes while Sherri went through some of our own tool sets set aside for other procedures. With some creative ingenuity the decompression surgery (laminotomies and foraminotomies) got underway, and 60 minutes into the operation we received our freshly-sterilized equipment.

That evening, the hospital and university invited us to a buffet dinner at the Agip Motel. Those in attendance included the surgical team from the hospital, the university and hospital accountants, and two of the vice deans from the Faculty of Medicine. After the meal, each of our hosts in turn spoke of their gratitude to Dr. Lieberman and his team. They expressed their hope that the continued presence of the mission would allow them to build competence and expertise in spine surgeries, ultimately establishing Mbarara as the pinnacle spine surgery center of East Africa.  After a week of hard work in the operating room, the team was moved to see the appreciation and long-term vision of our host institution. After all, we weren’t simply there to operate on ten patients and call it a week. The mission was established to provide spine care to the less fortunate and train those who serve these patients.  As the saying goes, “Give a man a fish and he will eat for a day. Teach a man to fish and he will eat for a lifetime.”

Image 5 dinner with Hosp & University faculty dinner with hospital and university faculty and staff

After dinner, the team gathered in our hotel lobby and discussed the lessons of the day over a bottle of wine. Today taught us that surgery can be seen as a series of small failures that simply require some creativity and perseverance to overcome. Back home in the US and Canada, the autoclave failure would have resulted in a canceled/delayed surgery. But here in Uganda, with limited time and even more limited resources, we could not afford to delay the operation. Dr. Lieberman, Rob and Sherri went back to basics in the absence of their standard operating procedures, highlighting the importance of fundamentals in medicine. We saw the challenges of the day—the power outages and the autoclave failure—as tests of what a co-ordinated and experienced surgical team could accomplish when forced to improvise.

August 16, 2013

Day 6

We were now starting to fall into a routine. We arrived at the hospital at our “usual” time. Sherri and Rob immediately started setting up the operating room and hunting for yesterday’s tools that we had sent for sterilization.  Meanwhile, Izzy, Zvi, Dr. Deo and I rounded on the two surgical patients from the day before. Dr. Deo led us to the surgical wards found in a separate building, much older and smaller than the one we were in. The ward consists of 8-10 private rooms flanking a dim, narrow hallway that opens up on either end to two large common rooms. The perimeter of each large room is lined with cots draped in sheets of all patterns, colours and sizes, leaving a narrow aisle down the centre. The colours are so distracting you could easily miss the patients sprawled on the beds. A stroll down the aisle (which elicits a cascade of curious stares) reveals entire families camped out on mats between and underneath the cots. Children squat and eat from containers of food prepared at home and brought to the hospital. (I later learned that Mbarara does not provide meals to admitted patients, save for malnourished children). It is clear that many have made these cots and mats their surrogate homes. The pathologies in the surgical ward are as eclectic as the bed sheets: limb amputations from motor vehicle accidents and gangrene, bowel obstructions, tuberculosis, breast cancers, malnourished and most disturbing, a young girl with severe burns after acid was thrown on her face. The contrast between this dilapidated surgical ward and the pristine operating theatres of the new building was astonishing.

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The women’s room in the surgical ward

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Families make the surgical ward their temporary home

After a quick visit with Muhamoud, our patient from yesterday afternoon, we left the surgical ward for the ICU where Amina, our first patient was recovering. We found Amina alert and sitting upright in her bed. Other than some pain around her surgical site, Amina was in fantastic shape. As we left the ICU, Dr. Lieberman smiled and sighed, “It’s a good life.” Our first patient, an 85 year old woman who could barely walk a day before, would live out her remaining years with a grossly improved quality of life.

Back in the operating room, the anesthesia team was prepping our first patient of the day. 28 year-old Naboth had survived a motor vehicle accident only to develop post-traumatic kyphosis (a forward bend of the spine across the collapsed bone).

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Dr. Emmanuel, the anesthesiologist, standing in our operating room at Mbarara Regional Referral Hospital

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Dr. Lieberman uses the Misonix, an ultrasonic scalpel that only cuts bone, on Naboth

The scene outside the hospital mimicked the drama inside our operating theatre. A heavy thunderstorm (the first rain Mbarara has seen this dry season and therefore a cause for excitement amongst our Ugandan colleagues) was beating down angrily on the hospital. Not surprisingly, Dr. Lieberman had to operate through multiple power outages throughout the day. Thankfully, the ventilator is on an emergency power generator. It was in the midst of this downpour that Dr. Lieberman, Danielle and I held our lunchtime clinic in the open-air corridor outside the operating wing.

Aside from a few more power outages, our second surgery of the day went surprisingly smoothly. This was the second step for Muhamoud, our patient from the previous day. Where his first operation used an anterior (frontal) approach to carve out his necrotic bone tissue, today’s operation would use a posterior (from the back) approach to stabilize and straighten his spine with screws and rods.

At dinner that night, the team discussed some of the mishaps over the last two days and discussed how “old school” is still very important.  The ability to adapt to the situation and circumstances at hand, and revert to basic skills is critical to success.

Day 7

Our first operation today was on a beautiful six-year old girl named Prudence. Prudence was born with a cervical rib, an extra rib that sits on top of the first rib and can cause the patient considerable pain. The plan was to remove the articulation (where two bones meet) between the cervical and first ribs. Dr. Lieberman would approach the rib from the left side of Prudence’s neck, very close to some of the most critical nerves and vessels of the upper body. While the team prepped the operating room, I stood and chatted with our little patient. She loves to play football (American soccer) and to watch television cartoons. She used to have four siblings, but her little brother passed away last year at age one from a “hole in his heart.” She was a brave little girl, staring up at the ceiling from her gurney and concentrating hard on hiding any fears about the operation.

Shortly after the surgery began, Dr. Lieberman encountered his first challenge of the day: a branch of the brachial plexus, the meshwork of nerves that provide motor and sensory function to the upper limbs and trunk, traveled directly above the anomalous cervical rib. This would require meticulously careful dissection to avoid leaving Prudence with a neurological problem following surgery. Dr. Lieberman navigated his way around the nerve and the neighbouring external jugular vein, found the cartilage and bone spicule of the articulation and resected without complication. When I went to visit Prudence in the surgical wards that afternoon, she was awake, talking, and most importantly, able to wiggle the fingers of her left hand!

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Prudence and her mother in the surgical wards within a few hours of her operation.

After a quick lunchtime clinic, it was on to our second surgery of the day. Rebecca was a 14 year old girl with a congenital hemivertebra (a wedge-shaped vertebra in place of the normal puck shape) and a consequent curve in her spine. The plan was to insert a series of screws and rods into her spine in order to correct the curve, while at the same time resecting the hemivertebra found slightly below the curve. As we prepped Rebecca for the operation, we realized that the operating table wouldn’t accommodate the semicircular arm of our Xray machine. Thinking quickly, Rob checked the operating theatre next door to us and found a woman practically in labour, conveniently perched on a more appropriate operating table. He explained our conundrum and soon enough the birthing mother was being hoisted onto a different bed while Rob snatched the replacement bed out from beneath her and wheeled it back to our OR. To our disappointment, the swapped bed turned out to be a dud too: it could ascend but not descend in height, particularly problematic for an “instrumentation” procedure like Rebecca’s. Finding the next quick solution, Rob brought each member of the surgical team an empty metal instruments box to use as a stepstool. We weren’t in the clear yet. The team flipped Rebecca over onto her belly to expose her spine and as I moved to prep her with an antimicrobial scrub, we realized that our Ugandan colleagues had forgotten to insert her catheter (usually done while the patient lies on his or her back). After a few groans and eye rolls, Rebecca’s catheter was inserted and then finally it was takeoff. Despite three power outages during the surgery (we eventually stopped being phased by the disruption), Rebecca’s surgery proceeded without complication. Our lesson of the day emerged from these mishaps, once again highlighting the importance of thinking quickly on your feet and improving in non-ideal circumstances. It can certainly be a challenge to move quickly and efficiently through patients when the standard procedures you are used to (like prepping and catheterizing a patient) aren’t stream-lined. But then again, life would be boring if we weren’t forced to adapt to new circumstances once in a while!

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L-R: Dr. Gorlick, Dr. Joeseph and Dr. Lieberman at the operating table

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A nursing student looks on as the surgical team operates on Rebecca.

Almost five hours later, the last stitches went into Rebecca’s back. Dr. Lieberman was visibly exhausted, having just completed his sixth operation in three days (not to mention the seventy-something other patients he’d examined in clinic).

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The screws used to stabilize and straighten Rebecca’s spine

After four consecutive dinners at the hotel restaurant, we were desperate for a change in menu. On the recommendation of our driver, we ventured into town for dinner at the Agip Motel restaurant. Despite being a bit skeptical of eating outside our hotel (for reasons of sanitation and stomach bugs), we surveyed the menu and the clientele and took the plunge. An hour, a bottle of wine and several beers later we were satiated and pleased with our decision. As we waited for our dessert to arrive, Dani pulled out her iPhone to show us an app called Heads Up, a charades like game created by Ellen Degeneres and her minions of funny people (so it HAD to be amusing). Sure enough, the team was soon doubled over in hysterics as Rob produced some uncanny impersonations of Sean Connery and Christopher Walken, Dani attempted a bald eagle, and Zvi and I collectively tried to morph into an elk. It was definitely a team bonding evening. We said goodnight to our waitress, Juliana, and promised her we’d return the following night.

It’s back to school time again, and each year many children get a new backpack to carry supplies, books, and homework. These carry-all backpacks often reflect the personality of the child, with many adorned with super heroes, princesses and more than a few Angry Birds.

back-to-school2While this efficient carrying case has been around for many years and has been used by millions of students both old and young, back experts such as Texas Back Institute physician Dr. Rey Bosita have noticed a problem with backpacks. They’re too heavy for some kids, and can cause long-term serious back problems.

We spent a few minutes with Dr. Bosita to get some guidelines on the proper size and use of backpacks. More on this later.

Backpacks Have a Colorful History

Backpacks, in one form or another, have been around since early humans used animal skins to carry meat from hunting trips. Just as with the school kids of today, these packs allowed prehistoric hunters to use the strong muscles in their backs to carry much more game for longer distances than if they were carrying it in their arms alone.

Historians note that the term “backpack” was coined by Americans around 1910; however, before it was known as a backpack, Europeans (specifically the Germans) called this carry-all a “rucksack,” which is a shortened version of the phrase “der Rucken” – German for “the human back.”

Up until the 1950’s, the backpack was primarily used for hunting and military purposes. These early versions were made of rugged materials and very heavy to carry. All of this changed when hiker Dick Kelty realized backpacks could serve a valuable function to the participants of his sport. He began experimenting with creating packs made of lighter materials and more compact designs. He also changed the weight distribution of the backpacks – by putting the skids of the pack in the back pockets of his hiking pants – allowing the hips to carry more of the load.

With this change, anyone who needed to carry several items while they were walking could pack these in a backpack and be on their way. It didn’t take long for parents and students to discover  these same, light-weight backpacks were ideal carrying cases for schoolbooks and homework papers.

The Problem with Backpacks

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For all of its efficiency, the modern backpack has its detractors, some of whom are backspecialists. In an article published in 2012 in the New York Times, it was noted that “heavy backpacks don’t just zap children of energy that might be better used doing schoolwork or playing sports. Lugging them can also lead to chronic back pain, accidents and possibly lifelong orthopedic damage.”

In this article on the dangers of backpacks for kids, the federal Consumer Product Safety Commission calculated that “carrying a 12-pound backpack to and from school and lifting it 10 times a day for an entire school year puts a cumulative load on youngsters’ bodies of 21,600 pounds – the equivalent of six mid-sized cars.”

In a 2012 report in the “Archives of Disease in Childhood,” researchers in Spain assessed the backpacks and back health of 1,403 pupils, ages 12 to 17. More than 60 percent were carrying packs weighing more than 10 percent of their body weight, and nearly one in five had schoolbags that weighed more than 15 percent of their own weight.

This study found that “1 in 4 students said they had suffered back pain for more than 15 days during the previous year; scoliosis – curvature of the spine – accounted for 70 percent of those with pain. The remaining 30 percent had either low back pain or contractures – continuous, involuntary muscle contractions.” Girls faced a greater risk of back pain than boys, and their risk increased with age.

Clearly, there is a potential problem with backpacks and kids. In many cases, they are either too heavy for the size of the child or they are being worn by the child incorrectly. We spoke with Dr. Rey Bosita, a spine specialist with Texas Back Institute, to get an idea on the “dos and don’ts” for backpacks with kids.

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Dr. Bosita noted pain often results when the weight of the pack pulls children backward, prompting them to bend forward or to arch their backs to keep the pack centered. These positions make the back muscles work harder and increase pressure on vertebrae on the discs between them.

If the child has to lean forward or seems unsteady when walking with a loaded pack, it’s too heavy.  This can lead to poor posture and shoulder pain.  Neck pain can also occur when the child is forced to look up from this position.

No parent or teacher wants a child to be injured by a backpack which is too heavy. So, what should be done to correct this situation? Dr. Bosita has some ideas.

Tips You Can Use for Back Safety and Backpacks

“The first thing we should look at is how the backpack fits the child and how he/she is standing while wearing it fully-loaded. The child should be standing straight up – with shoulders back. The backpack should be positioned in a manner that allows it to rest against the child’s back, straps a little tighter, so that the pack doesn’t sag too low,” Dr. Bosita notes.

Another important consideration for back safety is the weight of the backpack. What is the correct weight for a child’s backpack and how does a parent determine the weight of the pack? Dr. Bosita says, “The easiest way to determine the acceptable weight of the pack is to get the family scales out and weigh the child without his/her backpack. The weight of the backpack should be no more than 10 to 15 percent of the child’s weight. Therefore, if the child weighs 50 pounds, the backpack should not weigh more than 5 to 7 pounds.”

“Remember, everything adds weight to the backpack, including the pack itself, Dr. Bosita notes. “It’s a good idea to check the backpack weight with all of the materials connected to the pack (water bottles, knick knacks) and the books and school supplies being carried in the backpack (library books, binders).”

For the complete video of Dr. Bosita’s tips on backpacks, just click here 

Pack Only What’s Needed

When given the chance, younger children will stuff as many things as possible in their backpacks, much of which is not related to school work. Parents should take a minute each morning and afternoon to inventory the items being transported to and from school. If there are toys, games, handheld computer games, pet rocks, frogs and other non-academic items being packed in the bag, remind the child that these things should be left at home.

If he or she disagrees about the contents of the backpack, have a Plan B. Just tell them that you want them to grow up straight and tall and a heavy backpack might keep this from happening. This has the advantage of being the truth.

And if this fails, reward them with a treat  if they keep the back pack light.

Day 4

Today was our first full day at the hospital, although “full” is an understatement. When we opened the clinic at 10am, the open-air waiting room was teeming with patients and their families lining rows of benches or sprawled on mats on the floor.

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The team got right to work; Sherry and Rob left to set up our supply room and prepare equipment for surgery the next day. Izzy, Zvi, Danielle and I were joined by the hospital’s own orthopedic surgeon, Dr. Deo. We parked ourselves in a small room with an examining table and brought in the first patient. Over the next ten and a half hours, we screened 67 patients and selected 16 as candidates for surgery pending results from their imaging. It was a long day, and at times a bit trying; after hours of sitting on a bench in a dark, hot, narrow hallway with minimal food and water, patients began pushing their way into the small examining room. They were understandably anxious; many of them had travelled long distances to Mbarara just to be seen by Dr. Lieberman. We explained sympathetically that we were moving as fast as we could, and they would simply have to wait longer. I was astonished by their patience and resilience. Amina, a thin, frail 85-year old woman with chronic back pain from spinal stenosis shuffled slowly into the examining room with a walking stick. The deep wrinkles in her face folded into themselves each time she winced, emphasizing the extent of her pain. For over 5 hours she had waited quietly and without complaint. After his examination, Dr. Lieberman explained to Amina that he could treat her pain through a surgical procedure called a decompression, though the surgery would carry significant risk given her age. This brave elderly woman became our first surgical patient the following morning.

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As the day dragged on we began to appreciate a specific luxury of North American medical care: the process of waiting. To Canadians like myself and Zvi, waiting a month to see a specialist elicits a groan and some exasperated comment about “the drawbacks of universal healthcare.” Waiting over an hour in an air-conditioned waiting room with cushioned seats and a Starbucks in the lobby prompts a similar reaction. Many of these Ugandan patients had lived for over 20 years with back pain. We saw teenagers and 20-somethings with spine deformities that in North America would have been corrected within the first two decades of their lives.  Here, “waiting” is measured in years rather than weeks or months.

For some patients, their long-awaited visit with Dr. Lieberman brought bittersweet news: they were candidates for surgery, but would have to wait even longer. Kenneth, a short 18-year old with a pockmarked face and a big smile, was born with severe scoliosis and has developed restrictive lung disease as a result of his rigid spine. He walks stooped over to the right because his scoliosis forces his left shoulder upwards. Unable to work with his deformity, Kenneth was hoping that an operation would restore his physical mobility and give him “purpose,” as he put it. But to treat Kenneth’s condition the spine surgery team would need three weeks in Uganda, and we only have six operating days here. Dr. Lieberman explained to Kenneth that he would have to wait until next year when there is the possibility of a longer mission.

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67 patients later, we were done for the day. On the drive back to the hotel, we reflected on some of the cases from that day, including Bernadette, a 45 year-old woman who injured her back while pulling a goat tethered to her waist. When one team member wondered aloud why anyone would tie themselves to a goat, Rob kindly provided an answer, as well as our quote of the day: “If you haven’t mutton-busted, you haven’t lived.”

Day 5

A lot was riding on today: our first day in the OR, our chance to test out the facilities and to work alongside new Ugandan colleagues. Today’s successes and failures would mold our expectations of what we can accomplish in a week and would give us a sense of the challenges we would face. For that reason, Dr. Lieberman deliberately selected a relatively straightforward procedure for our first operation, a posterior decompression in which portions of bone are removed to allow more space around a nerve root. We arrived at the hospital around 8:30am and went straight to the operating room to find the anesthesiologist, Dr. Emanuel already prepping the patient, Amina.

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Sherri and Rob snapped into action and began setting up instrument tables and equipment while Izzy and Zvi scrubbed in. It seemed like we were off to a good start….. until the power shut off. We stood in the window-lit operating room with the patient on the ventilator for about 20 minutes until power returned. The rest of the operation went smoothly and two hours later Amina was on her way to the ICU.

 

 

 

 

 

 

 

 

 

 

 

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With a lunchtime clinic scheduled in between surgeries, we barely had time to scarf down our energy bars before heading out to the corridor of waiting patients. One by one, the patients approached Izzy and Zvi holding their X-rays and CT scans. We were able to add two patients to our list of surgical candidates, and sent several more for imaging and follow-up.

In the meantime, Sherri began setting up the OR for the next case, 56 year-old Muhamoud. Muhamoud had severe vertebral lysis caused by tuberculosis in his spine. I was particularly excited for this case because Dr. Lieberman was planning to approach the spine anteriorly (from the patient’s front), navigating around the peritoneum (the space behind the abdominal organs) to the vertebral column. As Dr. Lieberman went to make his incision, he looked up to find that the anesthesiologist had left the room, leaving his nurse anaesthetist in the pilot’s seat. This wasn’t the only hiccup we would encounter that afternoon. As Dr. Lieberman pulled back the iliac vein to find the vertebral column, the nurse anaesthetist tumbled from his chair, grabbed at the ventilator tubing and crashed into the operating room table causing the patient to move. It was simply luck that the vein between Dr. Lieberman’s forceps did not tear.

That night at dinner, the team discussed some of the lessons of the day. Our first two surgeries in new territory were sobering examples of the importance of thinking on your feet. When things don’t go as planned, improvise. Today’s challenges also highlighted some of the prerequisites of good teamwork. Teams of longstanding colleagues (like the Texas team) work like well-oiled machines. They anticipate each other’s moves, communicate effectively, share expectations and have standard procedures that help things move smoothly. When veteran teams join forces with new colleagues (as the Texas team did with the Ugandan anesthesia team), processes that used to be fluid can suddenly become turbulent. Care must be taken to communicate effectively, lay down expectations and establish roles and responsibilities. Perhaps today’s anesthetic troubles were not from a lack of competence, but rather from miscommunication and incongruent standard practices.

Finally, and on a more personal level, I learned today that surgery is far more multidimensional than I had thought. Spine surgeries don’t necessarily need to be approached from the back, just like heart surgeries aren’t always approached from the anterior chest. Each approach involves different anatomy and with that, different challenges, considerations and risks. The human body is sort of like a labyrinth for the surgeon; sometimes, the best way of reaching a point of interest is not necessarily the most direct route.

All in all, our first surgical day was a great success. As a team, we fell naturally into our own roles and got through our first two surgeries with only a couple nicks along the way. It seemed like we could count on a very productive and rewarding week ahead.

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