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.

Day 1

 

Annnnd we’re off! The 2013 Uganda Spine Surgery Mission officially began on Thursday, August 8 at London Heathrow Airport. This year’s team of six– the smallest team yet– gathered from a smattering of departure cities, including Dallas, Toronto and Tel Aviv. Flying in from Dallas were team lead Dr. Izzy Lieberman, his daughter (and chef extraordinaire) Danielle, and two veteran spine surgery missioners, scrub nurse Sherri LaCivita and medical equipment sales rep Rob Davis. Dr. Zvi Gorlick, a family physician in Toronto, joined the team for the first time, as did I (Jennifer Teichman), a medical student from the University of Toronto.

After a quick caffeine boost at the airport, we dumped our luggage at airport storage and scurried into London for the day. When a two-hour line thwarted our attempt to visit the Sherlock Holmes Museum, we hopped into a cab and found ourselves at Trafalgar Square after a quick drive-by of Buckingham Palace. All six of us clambered up the gigantic lion statues for our first team photo.

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Phone Booth

We met Ros Eisen, secretary of the Putti Village Assistance Organization for delectably crispy fish and chips at The Seashell, where Zvi insisted on ordering every dish on the menu that happened to be unavailable that day. Re-energized, we made our way to Big Ben, which several of us were surprised to learn referred to the bells rather than the clock tower itself. Dr. Lieberman surprised us with tickets for the London Eye, which proved to be the highlight of the day. We sipped champagne 40-something stories atop London and congratulated ourselves for a day well-spent. Then, it was back to Heathrow for our 9:00pm flight to Entebbe.

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The 2013 team on the London Eye

Quote of the day: “No time for dresses.”- Dr. Lieberman, after Danielle expressed a desire to change out of her yoga pants and into a dress for our day in London. We mean business!

 

Day 2

 

We touched down in a rainy Entebbe around 7:30am, sleepy-eyed yet itching to get started on the mission! Our collective enthusiasm met its first challenge when my laptop was stolen from the airplane. As a newcomer to the mission, I learned my first lesson of the trip: keep your valuables on you at all times, no exceptions. Our first driver, Eric, then appeared not with the 40-seat bus we thought was to be provided by the Mbrara University of Science and Technology (MUST), but with a small pickup truck and a 6-person van. This was my first hint that things don’t always go as planned in Uganda. We loaded the truck with our bags, piled ourselves into the van and started the bumpy 60 minute drive into Kampala, the capital and largest city in Uganda. Our first stop was Case Medical Centre, a private hospital that served as a base for the mission in previous years. This year, however, we were only there to pick up the medical equipment they had stored for us from last year.  Danielle and I held down the fort by the luggage-laden truck while the rest of the team retrieved the equipment. Rumor has it that while hoisting a big bag of surgical equipment, Zvi lamented Izzy’s choice of profession, and graciously provided us with our first quote of the day: “Why couldn’t you have been an ophthalmologist!?”

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After a true feat of space-maximization, the equipment was loaded into the truck and sent off to Mbarara to await our arrival the next day. Meanwhile, we headed to our Kampala accommodations, the Speke Hotel, for a much needed shower and change of clothes. With the whole afternoon still ahead of us, we paid a visit to the Galilee Community General Hospital, a Jewish Hospital in Kampala interested in future collaboration with the Uganda Spine Surgery Mission. We toured the facilities, including the new hospital building currently under construction. It was particularly interesting to learn about some of the considerations given to building and maintaining a small hospital on philanthropic support; the constraints of space, funds, resources and expertise were evident throughout our tour of the main hospital and construction site. Nevertheless, the team agreed that the new hospital promised to be a valuable addition to the community.

The team returned to the hotel to rest before dinner, a good idea since dinner turned out to be a marathon for the stomach and palate. We feasted on delicious Indian cuisine at Khyber Pass, one of two kitchens at the hotel and a favourite of previous incarnations of the Spine Surgery Mission. By the end of the night, several pants buttons were unbuttoned (mine included), and our droopy-eyed procession made its way to bed.

Quote of the day (#2): “I’m so full, I don’t even have room for a tic tac”

Day 3

 

Move in day! We awoke to a beautiful morning in Kampala, and hit the road after a hearty breakfast at the hotel. First stop: The Nakumatt Oasis, the Zeus of all department stores. There, amongst the impeccably clean and organized isles, one can find everything from toothpaste and vodka to washing machines and power tools. It puts Walmart to shame. After stocking up on what is reportedly the world’s best coffee beans, we piled back into the van and continued the five hour trek to Mbarara. Newly paved, the road to Mbarara traverses a landscape of rolling green hills, flat valleys of cultivated land and dirt paths dotted with shacks selling local fruit, meat, fish and potatoes. There was a collective cringe as we passed trailer after trailer of live bulls packed tighter than sardines, their ferocious horns piercing the air above them. Every half hour or so, the serene landscape was broken by the bustle and dirt of a small village with decrepit store fronts ironically painted in advertisements for Coca Cola and Nokia. Within an hour of the ride, our clothes were covered in a thin film of copper-red dirt kicked up by fellow drivers and boda-boda cyclists.

 

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We made a pit stop at the Ugandan equator, where we stretched our legs and shopped for local artisan crafts. Like school kids watching their first science experiment, Zvi, Rob and I oo-ed and aw-ed at a demonstration of water spinning in opposite directions in funnels placed on either side of the equator. Cooler still, water placed in a funnel centered on the equator didn’t spin at all as it drained! Call me a nerd….

We arrived at our hotel in Mbarara, the Lakeview, and were pleased to find large, comfortable rooms. Anxious to start our work, we gathered our medical equipment and drove to the Mbarara Regional Referral Hospital, our base for this year’s mission. We were met there by a spectacular surprise: last year, the hospital had opened an entirely new wing including an Intensive Care Unit, Emergency Department and operating theatres. We set to work right away, unloading the equipment from the truck and transporting it to a temporary storage room in the Emergency Department.

 

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Unloaded and eager to explore, we began a tour of the new building. The Emergency Department is a bustling continuum of corridors and open spaces filled with beds and curtains, each bed occupied by a patient and surrounded by family members. The spill-over of family members sit quietly on benches lining the hallways, many of whom carry infants. It seemed many of these families had not been home for days. Passed the Emergency Department, we found the ICU, a stark contrast to the crowded hallways of the ER. The ICU is a quiet space with each bed contained in a separate glass room. Computer monitors displaying patients’ vital signs hang over the beds, much like one would find in any hospital in North America. Already impressed, we then proceeded to the surgical wing. Dr. Lieberman’s expression was that of a kid in a candy shop when he first laid eyes on the operating rooms. Big, bright, clean, well-equipped and windowed… we hadn’t expected anything close to this! The team’s excitement was palpable.

We left the hospital elated and even more motivated to kick off a great week at Mbarare. After an “edible” dinner at the hotel, we headed to bed for a good sleep before our first big day at the hospital.

Quote of the day:

“It’s ok, you can take your skirt off here.. we’re all medical professionals”

“The food is…. edible….”

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Dr. Lieberman’s first glimpse of the OR

Update from Ethiopia

March 27, 2013

Surgery on that cutey was Sunday. She is doing great. It took a few days to coax another smile, but all is well. I have a lot of great cases to show when I get back.

Ted Belanger

Day 6: March 23rd, 2013

Here is a 13 year old cutie that will be having surgery this week.  She has a 60 degree thoracic scoliosis. For anyone not familiar, that means she is at very high risk for progression and will likely develop an 80, 90 or 100 degree curve over the next 2 to 3 years if left untreated.  Her surgery will be relatively straight forward now, and much more difficult (with possibly the need for more levels of fusion) and higher risk if done in the future.

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Her name is Mareg, which is a common name here.  Wish her (and me) luck.

Ted Belanger

Dr. Ted Belanger, one of Texas Back Institute’s orthopedic spine surgeons, is currently in Ethiopia where his is treating patients suffering from spinal conditions. Dr. Belanger will be sharing stories with us throughout his trip.

Below is his first blog entry!

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Day 1: 3/18/2013

Arrived safe and sound this morning in Addis Ababa, Ethiopia.

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Unfortunately, I am struggling with a cold that made my first day here pretty unproductive. I am hoping this will pass quickly. I am touching base with all of our various contacts here and getting some wild cases set up. My first one might be an os odontoideum with spinal cord compression and myelopathy. Yikes.

DAY 2: 3/19/2013

I am feeling a bit better. I accomplished a great deal yesterday. I saw 11 patients with various spine deformities in the clinic and we are finalizing workups to set them up for surgery. We may transfer a patient from another hospital that needs a C1-2 fusion (or so it has been suggested). I saw some old friends and met some new ones. I went to the customs authority to work on getting our supplies released, and I had to go through three large bins of equipment and identify each item and correlate it with the itemized list (think of….this is a tap, this is a screwdriver, this is a compressor, etc.) Luckily, I didn’t have to go to the length of identifying each individual screw by diameter and length. I did my best to stay positive and hide any impatience or American ego as best I could. Despite that major obstacle being overcome, our supplies have still not been released. I am hopeful they will be later today.

Day 4: 3/21/13

Did a big case yesterday.  Pedicle subtraction osteotomy for a chronic fracture that collapsed into kyphosis after being fixed with a short construct by one of the local surgeons.  Made it look pretty.  Have two scoliosis cases to do today, and every day until I come home…

– Ted

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