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.

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.

Trafalgar Square

 

 

 

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

Day 10 – Ebola?

Today we only had one case booked at Mulago hospital. We all woke up in the morning a little bit unsettled because we had all heard conflicting stories as to what the state of Mulago was in regard to the Ebola situation. Although most of the stories involved New Mulago, which is a part of the greater Mulago hospital, but located a short distance away, we were still not completely clear what was true and what was hearsay  As it stood, only half of the team was meant to go to Mulago to work on the case. There definitely seemed to be some tension within the team because it seemed like people were unhappy about this situation, but no one was speaking up. Thankfully, before we headed out, there was a team meeting called where we were told what was shared with Dr. Lieberman from the acting director of Mulago Hospital, and from his perspective it was safe for us to go in and perform the operation.

Off we went in the van, the group of us scheduled to do the case at Mulago. This case was an idiopathic scoliosis instrumentation, reduction and fusion on a 21-year-old female. Despite being slightly nervous about the Ebola situation, we all pulled together as a team and supported each other, mostly with lighthearted humor about the situation, and got through the case very successfully.

Day 11 – Last Day of Surgery at Mulago

Today there were two cases planned, one at each of the hospitals. At Case Hospital, we had planned to perform a difficult procedure on a 3-year-old female with a mass in the cervical region of her spinal cord. Knowing the delicate nature of this procedure, Dr. Holman had organized late last week to have some of his more specialized neurosurgery equipment shipped from the United States to help perform this procedure. Unfortunately, although it appeared that the shipment had arrived in Uganda, it was being held up by customs, and thus we were unable to obtain it. Consequently, this case had to be cancelled. This was such a frustrating outcome, after having planned to perform this procedure, and hopefully make a real difference for this little’s girl life, but instead the Ugandan government prevented this from happening.

While the Case half of the team were dealing with their setbacks, the other half of the team was working on a case at Mulago on a 50-year-old female with a suspected infection in her spine. This group at Mulago also faced their own set of obstacles in trying to undertake this case. When we arrived in the morning we found that the instruments we needed for the procedure had not yet been sterilized, and furthermore, the truck that was supposed to come and pick it all up to take it to where it can be sterilized, was out of gas. As we waited around for the necessary equipment, we rounded on patients, caught up on writing operative reports, grabbed a quick power nap, and Dr. Ughwanogho cracked the whip to ensure our patients were getting their post-operative x-rays after being told that they couldn’t get them because they had to pay for them themselves. Dr. Ughwanogho’s persistence paid off and sure enough, before we knew it we had all of the post-operative x-rays.

Finally, at around 1 pm, we had our instruments sterilized and returned, the patient was ready, and we began the case under the very competent leadership of Dr. Ughwanogho, with assistance from two Ugandan orthopedic residents. There was some uncertainty going into this case because this particular patient had been investigated for an infected process in her spine, but we did not know exactly what we would find. What we did find was a very inflamed spine, with cavitating lesions. Due to the precarious state of this patient’s bones, likely due to underlying  osteoporosis, this case took longer than we had anticipated; plus, we had had a considerable late start. Bottom line, it was a late night at Mulago, and when we finally had finished it was around 8 pm.

The rest of the team had gone to an evening reception, hosted by the Mulago administration, but as we had had a long and frustrating day, exhausted and starving, we headed home and went out to grab a late dinner. We eventually met up with the rest of the team at the apartments and discussed the trials and tribulations of the day, but encouraged by the positive outcome for the patient. Moreover, I think this was an important day for Dr. Ughwanogho, as he was able to reaffirm to himself just how talented and competent he is as a young orthopedic surgeon, even in the most adverse conditions.

Day 12 – Last Day in Uganda

Today, our last day in Uganda, was spent operating on a 5-year-old male with congenital scoliosis at Case Hospital. While half of the team was at Case operating, the other half of the team went to Mulago to wrap up any loose ends, check in on post-operative patients, and clean up our equipment. Once we had finished up at Mulago, we bid a bittersweet farewell to this place that had quickly become a home away from home for several of us. Although we had only been there for two weeks it became very apparent to us that we had established very strong and special relationships with the health care staff we had been working alongside; not to mention the relationships we had formed with the patients we had operated on and were now on their way to recovery. To me there was definitely a sentiment of this trip not being long enough. It seemed like just when we were starting to get into the swing of things, and starting to really mesh with the Mulago staff, it was time to go. Afterall, there is always more we could do.

Once we had finished up at Mulago, those of us who were not part of the operating team at Case went home to work on outstanding reports, sorting of the thousands of pictures that will be necessary to supplement the trip report, and catching up on other odds and ends. However, our ability to do work was interrupted by a building-wide power outage. Thankfully a generator was brought in, but only lasted as long as a full tank of gas, and then we were once again powerless. This made for more of relaxing afternoon that we had anticipated, but we were not too upset about that!

The operating team finished up the case successfully and without any complications. Upon their arrival home, we all packed up, sorted out the equipment that would be getting shipped back to the United States, and cleaned up the apartments, as we had an early morning departure on Friday morning. After all of our dirty work was completed, we gathered for our final team dinner at a restaurant called The Lawn. It was a lovely evening, with great food, drink, company and lasting stories and memories shared among us all. As usual we shared our personal lessons, but this time it was the lesson of the trip. Although we all shared very profound and meaningful lessons, it became obvious to me that this trip could never be summed up in a single lesson. Each of us has learned invaluable lessons from our patients, colleagues, from the Ugandan way of life as a whole; and more importantly learned more about ourselves than we probably even know. It is my hope that these lessons and memories remain strong and fresh in my mind for years to come.

Uganda Mission

November 6, 2012

Day 9 – Second Week Begins

Contributed by Erin Sadler

                Today marked the beginning of the second week of surgery. We had procedures taking place at both Mulago and Case Hospitals. At Case Hospital, Dr. Lieberman was performing a revision of hardware. At Mulago, Dr. Ughwanogho, one of Dr. Lieberman’s fellows, completed his first case on his own. He did a fantastic job operating on a 20 year old male with a cervical burst fracture. It was not only his surgical competency that I was so impressed by, but earlier in the day while he was rounding, Dr. Ughwanogho blew me away. It was during his interaction with a young man who had been in a motorcycle accident and had an odontoid fracture in his neck. After discussing with him the potential surgery that may be necessary for him, Dr. Ughwanogho proceeded to get to know more about the patient, and in doing so learned that he was in school training to be a pilot. Furthermore, learning the operation he had been suggesting, could potentially compromise this young man’s future career. Immediately, Dr. Ughwanogho realized these implications and quickly adapted his plan to accommodate an outcome that is more in favor of this young man’s future profession. Dr. Ughwanogho’s display of compassion and patient-focused care makes him a very strong role model that any surgeon-hopeful can, and should, look up to.

                After a long day, we arrived back home and turned on the television to watch some Olympics, but were quickly distracted by the CNN headlines of the Ebola outbreak in Uganda. After a few seconds of watching we were even more surprised to see a screen shot of the Mulago hospital, the hospital we had just operated at all last week, and all day today. Although we had been aware that Ebola was present in the Kibaale district, we were not informed of its presence at Mulago until now. This made most of us quite uneasy, and in no time family members were sending emails and texts sharing their concerns for our safety. We were later told that Mulago had not yet confirmed cases of Ebola, but there were several health care professionals being quarantined. We were more reassured when we heard that the airports were still open, there had been no travel restrictions placed on Uganda, and the belief from health officials that if there was any suspicious virus, it had been contained at Mulago.

                In an attempt to take our minds off of our worry about the current situation, we went for an absolutely incredible dinner at the Kampala Serena Hotel. This buffet dinner had the most delicious fresh avocado  smoked tilapia, beef kebabs, and a smorgasbord of desserts. After filling ourselves to the brim, we headed home. Before going to bed, much to the delight of our Polish anesthesiologists, we watched the Poland Men’s Beach Volleyball team (or as Jason astutely puts it, “sand” volleyball since they are not playing on a beach during this Olympics) defeat the USA team.  We then retired to bed, some us quite nervous as to what tomorrow would hold with respect to going to Mulago to operate, and furthermore, the implications of our travelling home with this health threat brewing.

Uganda Mission Day 8

November 5, 2012

Uganda Mission

We finally have the final blog posts from Dr. Lieberman’s Uganda trip!

Day 8 – Seeing More of Kampala

Contributed by Erin Sadler

The day started with some of the team heading off to round on post-operative patients at the respective hospitals. The others who remained at the apartments spent the morning doing laundry, finishing up some work, catching up on other odds and ends, plugged into the Olympics, and in Dr. Holman’s case: fighting a suspected case of food poisoning. In the early hours of the morning, it came to Ngozi’s and my attention that Dr. Holman was feeling under the weather. By the time the morning arrived he was feeling worse and we were all concerned that he had eaten something bad that was taking a toll on his system. It was no surprise that Liz took on the nurturing role of nurse to keep a close eye on him.

Once everyone had returned from rounding, we decided to spend the afternoon going to the art market and gain a more inside look at Kampala by visiting the city market. We had initially thought we would visit the Bujagali Falls, but the previous day, during our return from Putti, we had sat in traffic for over an hour, and thus we were hesitant to take this same route, and spend the afternoon baking in a vehicle stuck in bumper to bumper traffic. Instead, we settled on the local markets. After getting a grocery list from Liz with remedies for Dr. Holman, including salted crackers, ginger ale, and Lucozade, we headed off in the bus to exercise our bargaining skills at the market.

The art market is an area in the center of town where various vendors have set up booths and sell their goods. There is everything from jewelry to art, to authentic Ugandan clothing, pottery, and other trinkets. Going from booth to booth we began to appreciate not only the art of the vendors, but the art of bargaining the price down. This was best demonstrated when we were looking at the section of the market with paintings. It was quite entertaining to see Brian attempt to exercise his negotiating prowess to try and get a painting from 150000 shillings to 80000. Although he claims he “won” since he did not end up paying more than he wanted, he also walked away empty-handed because the artist wouldn’t budge below 90000. Others were more successful, and came away with treasures that they had negotiated to a reasonable price.

From the art market, we courageously ventured to the real Kampala city market where goods are bought, sold, and traded. This was an absolutely incredible experience, to gain an insider’s look at the local commerce of Uganda. We also gained important knowledge regarding appropriate attire to wear in Ugandan public: women should not wear shorts. Unbeknownst to me, wearing shorts is the closest thing to being naked, as in Ugandan culture, a women’s thighs should only be exposed to her husband. I guess I had to learn this lesson the hard way, as many of the locals were taking pictures and quite interested in the “Muzungu” who was “naked.” Needless to say, the group of us was quite a spectacle to see wandering through the maze of alley-ways filled with mountains of clothing, shoes, electronics, and various food products and other provisions. This visit did serve a greater purpose; upon seeing the glorious local produce, we were inspired to buy ingredients to make guacamole. Under the keen eye of Chef Brian, we selected and bought the finest avocados, garlic, onions, hot peppers and limes. After making our way safely back to the vans, with our purchases in tow, and the new knowledge of what not to wear, we headed home. After a quick stop at the Nakumatt (the 24 hour grocery store) to buy a few more key ingredients including cilantro, salt and chips, we arrived home, all of us anticipating Brian’s creation. I have to admit I was skeptical, but Brian proved to be quite the chef, and concocted some of the most delicious guacamole I have ever tasted.

After our delicious appetizer, we decided to have our second dinner at Khyper Pass, the delicious Indian restaurant we had gone to on the first evening. Unfortunately, Dr. Holman was still feeling sick, and after giving him a few litres of intravenous saline and reminding him what it is like to be on the patient side of health care, he was still not up for taking solid food, so we headed off without him, promising white rice upon our return.

With our bellies full and white rice for Dr. Holman, we returned home to play a lively game of “Things.” Hopefully you have played this game, because in my opinion it might be the most fun game ever created. Needless to say, the rest of the evening was filled with hysterical laughter, learning a lot about each other, perhaps even things we may not have wanted to know, and most importantly, the complexities of Brian’s relationship with his cat, Max.

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