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.

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