Day 5: Where’d that Patient Go?
As a premed student, there isn’t much I (Adam) can do in the operating room, but I’ve found other things to do. Taking notes on patients and keeping electronic copies of their records on a laptop, keeping track of possible surgical candidates, and probably the most important thing, keeping an up-to-date surgery schedule. Now, I’ve had no training and caught on fast on what to do, but Murphy’s Law caught me off guard, you know that line “Whatever can go wrong, will go wrong”? I made the mistake of almost forgetting it.
The day was going to be a good length; not long, not short. Four cases were planned; the removal and biopsy of a mass on a girl named Rebecca, an ACDF (Anterior Cervical Diseconomy and Fusion; it’s done remove bad disc [padding between vertebrae] and fuse the bones together) on a woman named Jolly, a decompression on a gentleman named George, and a simple injection to attempt to alleviate pain on another man by the name of Nehemiah.
Dr. Huang and I went on rounds again, visiting patients from all the days prior we had operated on. Wednesday’s patients, Bernard, Norah, and Medias K, were all feeling some post-op pain (to be expected), but doing alright. Derick, with his prior condition, could not communicate to us, but his parents stated that they saw improvement already. The patients from days prior, Denis, Medias, and now Godson, were all beginning to do even better; some saw larger improvements than others, but none the less, all were improving. Julius, however, was beginning to complain of a new pain in his hip, but his strength was okay. It was at the end of the rounds, we noticed a patient we had seen prior to the clinic, a boy with head trauma and inability to move his head side to side or forward, had returned, with the MRI we had requested to check for spinal cord damage. We spoke briefly to the boy, Antony, took the MRI and planned to look at it with Dr. Perry.
As usual at this point, we headed back to the OR, where we went our separate ways; he went to join those performing surgery, while I checked on both operating rooms, and inform Dr. Perry that the boy’s MRI was in my possession. Not long after I told her, she finished her decompression, and looked at the MRI, noting nothing unusual; the spinal cord looked perfect, and gave me directions to tell him; he could come out from the collar he was in, take muscle relaxants, do physical therapy, and no contact sports for 3 to 6 months because of a concussion as well.
I searched for Natasha, and together we went to inform Antony and his mother, as well as ask physical therapy to start working with him. They came, and feeling uncertain about working with him, asked us to take him to their neurologist, who then cleared him, saying there was no damage he could see either, but he should hold on the physical. We spoke with the family a little more and discharged them.


Natasha, who’s in charge of the surgical ward and prepping patients for surgery, and I made our way back to the OR when she informed me that prior to this, she was having difficulty finding Rebecca for her surgery. I was confident we’d locate her, no problem. I headed into the OR with Dr. Lieberman, thinking he’d be only halfway done, only to discover that, no, he was close to done. Oh boy. I checked on them and quickly left to find Dr. Stanly Kisinde, a local doctor who was very close to the team,  to see if he if had any idea where the girl was only to discover that he, too, was searching for her. He told me to wait before I told Dr. Lieberman, and quickly called the contact info we had, only to discover she wasn’t here.
Okay, okay. Now to tell Lieberman.
I head into the room I know Lieberman is in, only to see him walking out. I inform him that she wasn’t present. After a short discussion between doctors, it was determined that we’d simply move up the 4th case for the day, the epidural injection. In addition to this whole fiasco, Sherri, who was scrubbed at the time began experiencing some stomach distress. Dr. Perry quickly came to the rescue and assumed the role of scrub tech until the case was completed.
With everything under control, I went to watch the injection, but had to leave early to assist in prepping the surgery list for the following day. Natasha and I spoke again, giving each other information, and getting the status on the x-rays. She calmly informed me that one patient is unable to get their x-ray, as they can’t walk. We discussed possible ideas and parted ways. I met up with the rest of the crew at the end of an early day, and waited for Brian, who wasn’t feeling very good, (we believe he caught a cold from the draft wafting through his torn disposable scrubs). We went to finish prepping the tools for the following day. Once wrapped up, and patients tucked in, we went out to an early dinner. We again shared our lessons of the day, from which Brian and Sherrie (who was feeling better at this point) provided the back to back, quotes of the day, which caused us all to burst into laughter.
Our quotes for the day:
“There are no sick days in spine.” Brian Failla
“You’ve gotta know when to tap out.” Sherri LaCivita

With an early dinner in our stomachs and returning to the hotel, we decided to once again play Jenga, as Dr. Perry had never played Jenga. Work hard, play hard, you know? And let me tell you, playing that game with three surgeons is the most intense way to play it. We split into teams, Girls (Sherri, Kari, and Dr. Perry) VS Boys (Dr. Lieberman, Dr. Huang, and I), and thanks to Kari “Oops” Zagar, hitting the table with her knee in the All-Or-Nothing game, boys took it 3/0. Thanks Kari!
It was after this, knowing we had a long day on Friday, that we decided to call it a night and get our rest. We knew we’d need it.

Day 4: Now Begins the Long Days
One of the simple pleasures of this trip thus far has been having breakfast together every morning; Eggs, maybe French toast, sausage, tomatoes and tea. We laugh every morning and simply enjoy everyone’s company before we begin the work we came here to do.
Wednesday. We’ve finally completed the two days of clinics, seeing everyone in the clinic, sending some for new x-rays and MRIs so we could reassess them, and setting up the surgery schedule. Wednesday is when it picked up; four cases. Fusions, decompressions, revisions, and a neurosurgery case for a brain tumor; from this day to the end of the week, long days of surgery are planned.
Dr. Huang and I go on our rounds to check on our patients, with Natasha, a local general surgery resident assisting us in locating our post-operative patients in the wards and ICU [Intensive Care Unit]. We began with the three patients who had surgery the prior day; Medius, Godson, and Julius. Medius was doing well, and was able to stand up with some assistance, and take a few steps, however, she complained of a little discomfort. Godson was doing slightly better than before, as he complained of significant discomfort and pain, and was unable to stand at the time of us doing our rounds. Julius was doing well and told us of some discomfort from his surgery as well. The discomfort from every surgery is to be expected, as these are all major surgeries, and some irritation and pain are always anticipated.


Once finished, Dr. Huang and I make our way to the OR for today’s cases, which are already in progress. By the time our arrival in the OR, Dr. Perry had already finished the decompression on a woman named Norah, and was preparing for her neurosurgical case to relieve the pressure on the brain. He would do a biopsy on a brain tumor to determine truly what the tumor is. Dr. Huang quickly went to join them, while I headed to the other operating room (We had two rooms running at once to try and help get more cases done). Inside the second room, with Dr. Lieberman, they were performing a fusion on a gentleman named Bernard, who also had TB. Both cases going on at this point, the biopsy and the fusion, took many hours to complete.
During the hours these cases took place, I rotated between the two rooms, checking on everyone, but spent most of my time in the neurosurgery case, watching how it took place, and the tools used. The thing that stood out the most from this case, excluding the fact that it was neurosurgical, was the scope used. It differed greatly from the ones used in the States, and took some time to set up, adjust and prep. The case itself, however, went smoothly. In fact, all the cases went exceptionally smoothly, they were just taxing in terms of length.
We had a short time between cases to rest and grab a bite from the food provided by Sister Rose; warm bread and samosas. It was a fast lesson to everyone that the samosas should be consumed quickly before I could get to them, as I’d easily eat six or seven (and I had!). It was during this time though, when we glanced at Brian, that we had once again noted he tore his pants. Once, we could tolerate, but twice only proves that Brian has no inhibitions!
The last case was a revision on previous instrumentation done elsewhere that had not fused to the bone on a woman named Medias K. Her case, like the others went smoothly, as anticipated the screws and rods had worked their way loose and were simply lifted out of the surgical wound. It’s important to note, that instrumentation is not often removed, and should not come out in one piece, but should be disassembled.
The day ended at close to 9:15 PM, and eight fatigued men and women all piled into the bus very satisfied with the days accomplishments. Dr. Gorlick, being the intelligent man that he is, had called ahead and ordered the buffet for us; Chicken, fish, pasta, vegetables, and potatoes. Let me tell you, there isn’t much better than arriving at the place you’re staying, and knowing there’s warm, delicious food waiting for you. We ate, laughed, shared our lessons of the day, enjoying the food and everyone’s company once more.

​Day 3: I'm Feeling the Pressure


A typical morning; for some, a run. For others, more sleep. Close behind, group breakfast with warm food, and a fresh cup of coffee or tea. Shortly after, we jumped into the van with some bags, and headed off.

We arrived at the hospital, and split into two groups once again; Dr. Huang, Dr. Perry, and I all traveled to visit our only surgical case on Monday, while the rest remained to prep the operating room (OR, for short). He was put into the Intensive Care Unit (ICU) for the night, and was doing well, but still had some pain, discomfort, and still had little to no motor function in his legs. We checked his dressing on his incision, changed it, and headed up to regroup with Lieberman and the others.
The situation was pre determined; Dr. Gorlick, Dr. Perry and myself are to head back and meet the patients for the day, while the rest remain in the OR for more surgeries; a scoliosis correction and fusion on one girl, Medius, a decompression on a gentleman by the name of Godson, and a TB cleaning and spinal reconstruction on another gentleman by the name of Julius. We accepted, slightly disappointed not to be in the OR, but happy to still meet and try and do what we came here for; to help everyone and make a difference.

Similar to the previous day, every patient came in with different stories, and many patients shared similar conditions. And with every patient, came Dr. Perry examining them and their films, me rapidly typing everything into a chart, and Dr. Gorlick once again filling in the gaps I missed and completing the most important task; handing out lollipops, and eventually, thanks to Sister Rose, bringing both Dr. Perry and I the most delicious, homemade samosas and bread. However, it became frustrating, seeing so many patients and feeling like you're helping them, but not as much as you want to or as much as you could (AKA, the penalty box) With this feeling, after the 40 patient mark being the halfway point, we took a break and returned to the Doctor's Lounge for a short time. Dr. Perry went ahead, while Gorlick and I followed behind, and we all knew that the rest were doing the cases for the day. But, apparently, during our time in clinic, Brian, who remained with Dr. Lieberman, heard a loud tear, but was so entrenched in his work he didn't bother to investigate.  Later that afternoon between cases, he realized his paper scrubs tore, providing an unencumbered view of his fruit of the looms. 

Quote of the day provided by Brian:  "eyes up ladies"

Imagine walking into a room to a man whose clothes look like they're being held together through masking tape and a whole lotta hope.

It was a huge laugh for everyone who saw this, including Dr. Perry, who noticed it.

Once we regrouped, we talked about what we saw, what we'd like to do, and how we could speed up the process as we'd already spent roughly 5 hours on only 40 of the 80 patients, and the day was wearing out. What about being less thorough? No, we could miss something. Being faster? No, everyone deserves the same care. Running another room?
Hmm. That may work.
We went back to clinic, food in my hand to prevent us from any chance of hunger frustration, or "hanger" from affecting us due to lack of time to eat. Dr. Gorlick, and another orthopedic surgeon,  Dr. Kinsitu, each took a room, and we all began seeing patients. If there was any doubt from either of the other rooms, they came in, chatted briefly with Dr. Perry, came to an agreement, and resumed their patient meetings and consultations.

Meanwhile, back in the OR, they were having their own fun. With spine surgeries, you have someone in a role called "Neuromonitor", who, through a series of needles and wires carefully placed into the arms and legs, makes sure that when correction of the main problem takes place, no nerves or the spinal.cord are damage and there's no loss of motor function. In the first fusion, they had to be extremely careful, as over correction caused the monitoring signals to fade meaning a possible decrease in function. But, thanks to Kari, this was all avoided. Their decompression went well, but the other TB case was messy; the infection was far worse than expected,  but still cleanable, so they began the long task of cleaning his vertebrae.

Both teams finished in the early evening, and hungry, we returned to the hotel to a warm buffet of fish, pasta, chicken, and a few other things are cooked and ready for us thanks to Dr. Gorlick's idea of calling the order of a buffet ahead of time. And let me tell you, there is nothing better than a long day of work, and returning to a warm, delicious dinner all ready to be eaten.

​Day 2: Let's Get Started!


One thing about working as or working with a doctor is the early mornings; there's no such thing as sleeping in when there's stuff to do. So, 5:00 AM rolled up, and some of us got up to head to a pilates class held by Dr. Lieberman, while some of us could barely muster the strength to get out from under the covers of the bed.
6:30 AM came up, and those of us who couldn't get up finally had; everyone was showering, changing into scrubs, and heading towards breakfast before we made our way towards the hospital to begin the work we came here for. The food was warm, and the tea sweet; the most perfect thing to wake up to. Thus, we all regrouped, ate, and left towards the hospital.

We arrived, and immediately got to work. While half of us split to prep the operating room, the doctors and I went to view a few patients in the private ward. Of the four patients seen here, two had surgery proposed, and one accepted; a man by the name of Denis, who had Tuberculosis that had developed into Pott's Disease, which is when the TB is seen outside the lungs and present in the vertebrae (bones of the spine) However, due to inflammation or swelling from this, he is unable to walk and completely bedridden, but we expect him to quickly recover, and with a few days time, once again walk.

With these patients seen, we split into two teams; Dr. Lieberman, Dr. Gorlick, and I all headed to clinic to meet all the patients, while the rest traveled to the operating room for the case.
Clinic was quite an experience, seeing so many patients, each with their own, unique story and situation. Maybe patient A had scoliosis from birth, while patient B had scoliosis from old age, but each were in a situation to avoid surgery through exercise. Some were young, others old. No one was the same. The three of us quickly figured out a routine within clinic; I acted as the scribe, recording vital information, Dr. Lieberman examined, and Dr. Gorlick assisted with filling in the information I was unable to get, as well as handing out suckers to our younger patients.
After a few hours of clinic, we briefly stepped out to check on the others in surgery, and as a reason to stretch our legs on our way to a short call. The three of us arrived to see the case in progress, halfway completed, with not a single problem. The TB was being cleaned out, and the fusion was all moving smoothly along. We chatted shortly about a few things; the case in progress, cases we hoped to do in the next few days, dinner, and headed back to resume our work.
Clinic continued on, with us doing our best to provide care and options to each patient; men and women, boys and girls, we saw everyone. Notes were taken on each patient; One girl has macrodactyly, or really big toes, in addition to back problems. Another girl has a mass on the back that needs removed and analyzed. And with every patient that wanted one, a lollypop was handed out. And, with every lollypop came the same smile. Once the surgery on Denis was completed, a second room to examine patients in clinic was opened with Dr. Perry and Dr. Huang running it, and we continued on.

At the end of the day, a grand total of 79 patients were seen in clinic, with additional 4 in the private ward, and another 9 seen in the neurological ward, for a grand total of 92. Three of those cases were chosen for surgery the following day.

We packed up, and returned to the hotel to discuss more surgical plans over dinner. Who needed what and when? Could it wait for a year? Did we also have all the equipment necessary? Cases were thought upon, and names set up over a warm dinner of chicken, fish, pasta, and rice. At the end of the night, happy with the food in our stomachs and the decisions made, sleep called back to us.

​Day 1 and 1/2: Arrival in Uganda

Whenever you travel, there's always the concern about baggage; Did it all make it on the right flight? Did it arrive? Was it searched? Can I retrieve it? It's a little different on a mission trip such as this, in the sense that these questions make you a little more worried; Are the sterile items in the bins open and contaminated? Did my bags with my supplies make it? Did they remove something?
We arrived in Entebbe in the evening, and after retrieving visas, making sure we were all together, the crew headed to retrieve our bags and bins of supplies. The crew, this year, consists of two teams over two weeks. Week 1 consists of Dr. Isador Lieberman from Texas Back Institute in Texas, Dr. Steve Gorlick, from Toronto, Canada, Dr. Tiffany Grace Perry from Los Angeles, California, and Dr. Meng Huang, a 5th year neurosurgery resident at Houston Methodist. In addition, we have Kari Zagar, the neuromonitor, Sherri LaCivita, the scrub technician, Brian Failla, hardware rep from Globus Medical and myself, Adam Woodward, a premed student.
We slowly see personal bags come out, and the bins all set to the side. While two remain to guard the bags we had on us, some went to retrieve the bins, and others the personal belongings. Once all were grabbed and counted, we realized we were missing 3 bags; one of extra medical supplies Dr. Huang brought, and Dr. Perry's bags, containing all of her clothes, scrubs, and some other personal belongings. After some inquiries and searching, it was determined that their bags never made it in the plane, but we could easily adjust to the situation.
With that in mind, we found the van taking us to Mbarara, packed our bags inside, filed in and began the long trek from Entebbe to Mbarara. 

The following morning, after some much needed sleep due to an early morning arrival, we left from the Lake Side Hotel to the hospital, with the intent of unpacking what seemed like countless boxes of medical, both newly brought and remaining from previous years. The arrival was nice; old friends were met once again, and new friends made. We met and spoke with (Normun?), head of the operating room, who then kindly showed us where we'd be storing all the supplies. After discussing a few rules (you must change shoes when entering the OR to prevent contamination, hats must be worn in the rooms), we went to work on the few hour task of unloading and sorting supplies, in addition to setting up trays of with tools to be sterilized. But, as the saying goes, "work hard, play hard", we found ways to laugh during the work. While wrapping tools to be sterilized, Dr. Gorlick was called over to help wrap, to which he chucked, "Don't worry guys, I'm the bondage king!". It was hard to continue through the laughter for a few minutes.
We finished up the necessary work, and went to the town to get some waters, and get Dr. Perry some fresh clothes. Mbarara is filled with life; people bustling through the busy town, the shops filled with people, all buying and selling goods. We found some of what we were searching for, went to another shop, and returned to relax.
And after a long day, what's better than a game of Jenga with a bunch of friends? Sure, tensions were high and no one touched the table during the games, but it was extremely enjoyable for all parties involved; especially when Dr. Meng was struggling to find a good block to pull, so he jokingly said "I'm going to need my loops for this..." The laughing was so bad, he almost lost the game then and there.

Dinner rolled around, and as per tradition, the fried fish was ordered, and was absolutely amazing. Warm and flaky on the inside, but crunchy and flavor on the outside.
At the end of dinner, we all recounted what we learned through the day, and the thing that stuck out to me the most was that nothing goes to waste here. Tying the tools to be sterilized, gauze was tied together and used, and will be reused to tie more together when necessary. It was very different than in the US, when most things are disposable in a hospital.

Thus, ended our first day and a half.

​The next day, we went to the hospital one last time to round on our patients before taking the bus to Entebbe, where many of us began the trip back home.

​Priscilla (our scoliosis patient who had surgery Wednesday) is recovering well and standing up straight. The pain tolerance and determination of many of our patients in Uganda has been astounding. None of them have had any IV pain medications post-operatively, yet most are up and about the first day after surgery.
 
On the bus ride back to Entebbe, we took a scenic shortcut to avoid “jam” (which is what they call traffic in Uganda). Not only did we shave an hour or so off of the 6-hour drive, we also were treated to some nice views of the countryside.

​Megan: “Are there any liquor stores around here?”
 
We stopped by the equator line on the way to Entebbe for coffee and pictures. They have an interesting set up at the equator line with three bowls: one in the northern hemisphere, one on the equator line, and one in the southern hemisphere – all three no more than 10 feet away from one another. When water is allowed to drain from each of the bowls, the resulting water funnel twists in opposite directions on the north vs. the south side, while the water draining from the bowl directly on the equator line doesn’t seem to spin at all. A bit hard to believe at first, but we saw it with our own eyes, and even switched the bowls around to be sure it wasn’t a trick.
 

​ 
With that, the trip – and the blog - have come to an end. This mission has been a unique and transformative experience for me in many ways, and I have taken from Uganda many lessons and memories that will surely stay with me for the rest of my life.
 
As a special sign off, we leave you with a fantastic video that Michelle has put together to chronicle the July 2016 Mission.
 
Wishing everyone in Uganda and elsewhere a safe and happy year. Thank you to the many people who came together to make this trip possible.
 
https://www.youtube.com/watch?v=262wUxLGBeI&feature=youtu.be
 

Today is the final operative day of the mission, and we intend to sprint through the finish line. The hospital graciously allowed us to use two O.R. rooms today, as we have 5 operative cases that we hope to finish before we leave. Everyone buckled down and really came together to get things done today.
 
The surgeries for the day included: two anterior cervical discectomies and fusions (one for degenerative disease and radiculopathy and the other for trauma) and three lumbar decompressions and fusions for adult degenerative spine disease. Much of the equipment had to be run back and forth between the rooms during the cases, as we didn’t have enough C-arms, bovies and drills to run both rooms simultaneously.

​After the operative cases were done, we still had to pack most of our equipment back into tubs to take with us to the warehouse for storage or back to the states to the companies and individuals from whom we had borrow them. Luckily, Lance is a beast, and had cleaned and packed most of the instruments and other equipment before we were even done operating.

​Our last night in the Mbarara O.R.
 
Exhausted, we made it back to the hotel in time for dinner and packing up our luggage. 

​The big operative case of the day was a young lady named Priscilla who had idiopathic scoliosis. Priscilla is a nursing student in her final few months of nursing school. She has been trying for years to visit our mission and have surgery, but because of issues with timing, she has never had the opportunity to have her deformity corrected. This year, the stars aligned and we were able to see Priscilla and schedule her for surgery. This meant that she would have to take a leave of absence from school for several months, and although this would set her back a bit in the process of becoming a nurse, she did not want to let the chance slip away again. We spent the morning and early afternoon correcting her deformity and fusing her spine into a new, straighter position. 

​Our second patient was a young lady named Jolly who presented with back and leg pain. She was found to have fractures and erosion at L2-L3; the appearance was suggestive of an infectious process. Indeed, when we reached the area of the fracture, we found infectious material within the disc space. This was removed along with part of the eroded/fracture vertebral bodies and her spine was instrumented into a more normal alignment. We sent cultures of the infectious material and placed some antibiotic powder into the wound before closing.
 

​During the day, Dr. St. Clair saw several new patients in the wards, one of whom was a man with a cervical spine injury in need of stabilization. The practice of carrying objects on one’s head has existed for centuries in Africa and other developing countries. Unfortunately, this patient was carrying a large load of firewood on his head when he tripped, applying a heavy flexion and axial compression force to his neck, which resulted in a fracture/dislocation at C4/C5. He lost function in his arms and legs almost immediately after the injury, and because the event occurred days before he reached us, his prognosis for recovery of limb function was poor, but he was in need of stabilization to prevent and further deformity or injury from occurring.  We took the patient to the operating room after our second case, where we reduced the dislocation and removed some herniated disc material that was compressing his spinal cord at that level.

​… And then there were eight. Dr. Kerner and her plastics crew left for the airport this morning. Leaving us with a bit of a skeleton crew for the final stretch. We were all sad to see them go. 

​One last group shot with Dr. Kerner and her team. Left to right: Sue, Lance, Lorna, Sean, Megan, Dr. Kerner, Dr. St. Clair, Jordan, Bogden, Alvina and Michelle.
 
We started the operative day with a 12-year-old girl, Sheila, with congenital scoliosis. We instrumented her spine from T3-T12 and Dr. St. Clair performed some corrective maneuvers to get her spine into a more normal alignment.
 

​Our third case was an L3 – L5 decompression and fusion in a lady with back and leg pain.
 
 
Several of our patients presented with lower extremity weakness that persisted despite our interventions. We worked with local suppliers to acquire wheelchairs for these patients to assist with mobility, and many have begun to become accustomed to using a wheelchair around the hospital grounds. Michelle and Jordan even enlisted some of the youngsters nearby (who were eager to help) in the wheelchair training process.