Day 4: Murphy StrikesBreakfast was like the calm before the storm; no one truly knew what was going to happen, but we knew it would be a busy day. We had planned one instrumentation and fusion and one posterior lumbar instrumentation and fusion for the morning, and occiput (bone at the bottom of your skull) and C3 vertebra (the third vertebra in the neck) and anterior cervical discectomy and fusion (removal of the disc). Two long cases, and two short cases sounds ideal, but as Murphy’s Law states “anything that can go wrong, will go wrong, at the worst possible moment”.
We arrive at the hospital and immediately break into our separate groups; rounds and OR. Dr. Villarreal, Dr. Kisinde, Dr. Hisey, Sydnie and I all made our way down to the surgical ward, where we saw all of the previous surgical patients. All the patients were doing fantastic, and some, such as Jecinta (who had surgery on Tuesday) was up and walking with the help of our lovely physical therapist, Michelle. Others, such as Clency (one of the two little girls who had surgery on Tuesday) was doing better than she was previously, but still wasn’t doing as well as we had all hoped she would. With a little bit of encouragement and a few painkillers to make her more comfortable and alleviate her pain from such a large surgery, we hoped to see her begin to improve. With our rounds rapidly hitting its conclusion for the day, we returned to the OR where Dr. Hisey went to the one operating room to begin, while Dr. Villarreal went to join Dr. Lieberman in the other.
However, life doesn’t always intend for things to move smoothly, and always like to keep you on your toes.
Once Dr. Hisey entered his operating room with everyone who was going to assist him, they noticed the anesthesia machine was not working properly, saying there was no oxygen. Now, while a patient is sedated, the machine helps them breathe by filling their lungs with oxygen, so the machine saying there isn’t any is a rather significant problem. The technicians worked as hard as they could to get the machine up and running, and after about an hour of hard work, they finally managed to fix it! Now, as they went to retrieve the patient, they couldn’t find him. It wasn’t a matter of he wasn’t in hospital, as he was here and waiting in the back for the machine to be fixed, but more a matter of he just walked off for a bit. We frantically searched for what felt like an eternity (but was more like 5 minutes) and he just came back, all ready as long as we were, so we set to work.
Two cases would eventually turn to three, as Dr. Hisey finished his first case, and moved onto the second, while Dr. Lieberman and Dr. Villarreal continued work on case; a young girl named Promise in need of a large instrumentation and fusion procedure, which required caution due to the shape of her scoliosis, and the size (her T5 vertebra to her L3 vertebra). With one this size and severity, caution must be taken to prevent loss of movement in her legs, or further damage to her nerves.
Cases two and three became our final case, case four. This one was on a young man named Stephano, which we knew would take a while to complete. You see, his diagnosis was an interesting one, as the bone at the base of his skull, the occiput, fused on its own to his very top vertebra, C1 (Fun fact, it’s also known as “Atlas” because it holds supports the globe of your head, after the Greek myth Atlas, who holds the world up on his shoulders). This auto-fusion, in turn, caused compression on his spinal cord and further complications, such as sudden weakness in his right side. This procedure would (as expected), turn out to be a long case, as it must be approach with extreme caution. It was planned to fuse his occiput bone to his C3 vertebra, and to decompress the spinal cord, in an attempt to have him regain motor function
The night came to a late close, and  we prepared to return back to the hotel for a well-earned night of sleep and rest, realizing that week 1 was slowly approaching an end. Little did we know, however, that while today was stressful, the rest of the week would hold more interesting surprises for us, never letting us relax for too long.

Day 3: Clinic Queues

​Another morning, another breakfast, another bus ride to the clinic, however, instead of our usual bus, we had a much more entertaining situation. The previous night, our normal bus driver wasn’t there, so someone else drove us to the hotel. The problem was, the bus we were taking was significantly smaller than what we needed. While it fit 12, we had to fit a grand total of 16 (including our driver). So, we piled in, got very close to each other, cracked a few clown car jokes, and made our way to the hospital to begin a multitude of surgeries and return to the penalty box, aka clinic.
We arrived (we still had a few packed bags needing to be unpacked), and quickly went to work. While most of us prepped the two ORs we were going to use, Dr. Villarreal, Dr. Kisinde, and Sydnie made their way down to the ward to check on the previous day’s patient, who was doing well. After a quick peek of his incision, change of his dressing, and seeing him doing well, they quickly returned to the rest of us, where we were close to completing the final touches on the ORs for the surgeries.
There was a lot of bustling around as patients were being brought in and put to sleep, x-rays were being put up and looked at, table were being prepped and steriley covered with tools placed on top, and people were beginning to scrub in. But, even through all this chaos, there was a method to the madness. People knew where to go and what to do without being asked, everyone knew what to grab, and what cases were about to happen. In the first room, we had a patient by the name of Jecinta who returned to us with two broken rods, so the plan was to exchange the broken rods. The second room had a 52 year young man named Edward who required a simple (nothing in spine Surgery is simple) 1 level fusion of his cervical (neck) vertebrae at C4 to C5.
Surgeries started, and Dr. Lieberman, Dr. Kisinde, and I headed down to resume clinic from the previous day, where countless patients were still waiting from the day before. Shocked, we quickly entered the exam room, prepared ourselves, and started seeing patients. Dr. Lieberman would talk and examine them, Dr. Kisinde would translate and also examine them, and I would record the patient’s history and diagnosis. Of course, seeing each patient and listening to them takes time, so after the first 10 patients, Dr. Lieberman made the executive decision to see a total of 50 for the day before he heads to surgery, and more would be seen during the second week of the mission. Charts were collected, and patients continued to come in one by one; low back pain, neck pain, pain or numbness radiating into the hands and/or feet. You name it when it comes to back problems, we probably saw it.
After a few breaks for our stomachs and mother nature, and the help of Dr. Hisey after his first surgery was completed, we finished seeing 58 patients, and made our way to the OR, where cases 3 and 4 were beginning to get ready. Case 3 a young girl named Clency who required a large instrumentation and fusion in her back, while case 4 was another young girl named Prima who was had a mass removed from her back. Once again, the ORs and the doctor’s room we were inhabiting started bustling with activity as we moved to prepare the next two cases; imaging, cleaning, equipment and supplies needed, people ready.
Once the cases began, and those of us not directly involved in the surgeries took a short break to grab a snack, or (a crowd favorite here) sit down. While all the cases were in progress, including cases 1 and 2, Sherron and Sydnie were continuing to unpack and organize a room, so when clinic was over and those of us there returned, Sydnie proudly told us that the task Sherron had given her was “complete”, and she went to watch the surgeries.
Both cases progressed smoothly and came to an end close to 7:00 PM, so we did our fantastic clown car routine, piled into the small van, and headed back to the hotel, where we ate dinner and laughed at different stories and Jason. He hypothesized that if he drinks a little bit of vodka every night, it will kill all the bacteria in his stomach and he won’t get sick from anything, and then took a drink. Needless to say, everyone became invested in his hypothesis, and we are all awaiting the results from his experiment. Then came the lessons of the day. As per usual, everyone shared what they learned, when we got to Sherron, who looked at us, chuckled, and said, “What I learned is the terminology for “complete” for millennials is different than older generations.” By this point, we all knew that Sydnie had completed the room in her eyes, but not in Sherron’s, and started cracking up.
The rest of the evening was uneventful;  a few of us parted ways, exhausted from the day’s work and ready for bed, while the rest continued to test Jason’s hypothesis and enjoy each other’s company. Little did we know what Wednesday would have in store for us.

Day 2: Exactly how much did we pack?

The morning was pretty typical to trips in the past; some got up early and worked out, some took care of emails and everything, and others slept in until the last possible minute before the standard team breakfast, where we’d discuss the tentative plan for the day.

In the one year since I’ve been in Uganda, change is present, whether it be in the form of new highways and paved roads, or new buildings being built in Mbarara. But the familiarity of the hospital was pleasant as we drove down the road, ready to unpack our luggage and start a clinic. At the hospital, we unloaded what felt like countless boxes of supplies from the bus. Some unloaded them, some carried them in, and some started organizing and packing, creating a perfect system. The boxes slowly began to line the walls of the hallway and the rooms we were occupying, and when you try and fit 15 people in two rooms and a hallway with a bunch of boxes, it gets pretty cramped. As we finished up with the  majority of the supplies, the truck containing more arrived, and the unpacking once again resumed in the same manner. As we unpacked, we would pass one another, with either a new box or an armful of some sort necessary supplies destined to the sorted and stored in the storage room by Sherron and Sherri, and one by one, the boxes emptied. While most of us emptied the bins, the doctors, Sydnie, Michelle and myself ran off to visit a few patients, and in viewing one gentleman, it was decided to do a surgery on him to clean an infection and perform a laminotomy (a surgery that relieves pressure in the vertebral canal).

With the truck and bus now empty, we split into two main teams; Operating room (OR) prep, and a clinic team. Preparing the OR, we left Dr. Benton, Sherri, Sherron, Jason, Joel (who spent a good majority of time repairing the C-arm, which is used to take x-rays during the surgeries), Brian and Kari. For clinic, Dr. Hisey, Dr. Lieberman, and Dr. Villerreal seeing patients , Dr. Gorlick, Sydnie, Michelle, and myself (Adam) scribed for the three clinic rooms, while Dr. Kisinde, Dr. Kisitu, and Dr. Tuhumwira translated for those who could not understand.
The day went by as smoothly as it can, when, you know, anything could happen at any time. Dr. Benton’s vaporizer blew a fuse upon being plugged in when testing it, so she had to adjust her plan for the rest of the week and use a different anesthetic gas than she initially planned. Other than that, OR prep went by well, with supplies being wrapped up and set to be sterilized rapidly, and everything being positioned and set up the way the teams would need them for surgery for the afternoon and following days.

Time for surgery came about, and Dr. Villerreal left clinic to perform the surgery, where he left clinic and Dr. Hisey and Dr. Lieberman continued to run, with Michelle, Dr. Gorlick, Sydnie and I continuing to scribe, where an estimated 60 patients were seen through the entire day. As surgery occurred, clinic and unpacking continued for a few more hours until clinic wrapped up, unpacking was called for the day (with a lot more boxes, bags and bins still needing to be opened and emptied), and the surgery was successful.
​
We left the hospital and returned to the hotel, where we had our team dinner before sharing lessons we learned for the day (everyday, no matter what, you should learn something). Afterwards, we split, some of us arm wrestling each other, and others passing out for the day, finally able to get a good night’s rest after so much travel and a long day of work, knowing another one was right in front of us.

Day 1: Oh, the places you’ll go

After many hours of international air travel, landing us in Doha, Qatar for a night, a majority of team 1 was able to reunite. Attending team 1 was Dr. Isador Lieberman, Dr. Michael Hisey, Dr. Jaime Villerreal, spinal fellow, all from Texas Back Institute, along with Dr. Susan Benton from Plano, Texas, taking care of anesthesia, and Dr. Steve Gorlick from Toronto. In addition, we have Kari Zagar, the neuromonitoring technician, Sherri LaCivita and Jason Ash, scrub technicians, Joel Tanner, radiology technician, Brian Failla, hardware representative from Globus Medical, Sydnie Ozanus, undergrad, and myself, Adam Woodward, undergrad.

We slowly made our way to our respective hotels, and with those currently in the city, we were split between 4 hotels throughout town.
When we all finally got to our hotels, we took a short break to unwind from the long 15 hour flight before dinner; naps, exploration, and catching up on emails and social media. A reservation was made for a restaurant called “Persia”, which was absolutely fantastic, both in terms of looks and the quality of food. The interior was gorgeously decorated, with paintings in alcoves you could sit and eat in, and food that was unbelievably perfect. We took our sweet time at dinner, even though the restaurant did not serve any alcohol, enjoying each other’s company, the food, and sights. But of course, everything must come to an end, so we returned to our hotels to call it a night before our early flight to Entebbe to begin the final leg of the journey.
Sleep took many of us that night, and we traveled down to the airport, where we explored and bought souvenirs before climbing into a plane for another long and uneventful flight, where we would then meet up with Sherron Willson, resident nurse (RN), Michelle White, our physical therapist, and Stanley Kisinde, a local doctor who is currently doing his orthopaedic residency in South Africa and has been a valued team member for the past 3 years.
With such a large group of 15 volunteers and over 40 pieces of luggage and storage totes, comes many new problems not commonly encountered on prior trips, like having so many boxes of necessary medical equipment and supplies that either we could (A) fill the bus with everything and not fit all the people, or (B) Fit all the people and not all of the supplies. Dr. Lieberman strategically initiated the audible and made some calls to local friends, and planned to fill the bus as much as we could, and have the rest of the supplies delivered to Mbarara the following morning, so we could have them for surgeries beginning on Tuesday. So, while we waited on the truck to arrive to carry supplies on Monday, we played Tetris on a much larger scale, fitting boxes, backpacks, and suitcases into the bus as carefully as we could. Once satisfied and the other vehicle was filled and secured, we all got to know one another as we piled into the bus very close to one another and began the long drive to Mbarara.
The drive was long and uneventful as we headed to the equator to stop for dinner, eating at Café Equator and strolling through some of the local shops for more souvenirs. We took our time, enjoying the fantastic food, air, environment, and  the chance to stretch our legs before we all piled back into the bus and resumed our trip, where many of us let sleep overtake us, giving some of us the bizarre ability to sleep with our face pressed against the window, even while the bus drove over bumps.
We arrived in Mbarara, where we unpacked the necessities from the bus (our personal belongings and clothes), received our roommate assignments, and called it a night, preparing for an early morning at the hospital.

With all the surgeries being done under incredulous circumstances the team ventured to the wards to round on the post op patients. Most nurses and caregivers were on strike, so our challenges continued.  The general wards were divided into a male, female, and pediatric section.  When we entered the building, the concrete floors were covered with water with the morning cleaning crew sweeping the water across the surface to make them as clean as possible.  Blankets and food containers from overnight stays of the families lined the room surrounding the patient beds, which were about 18 inches apart.  Families were our biggest allies when rounding on their loved ones.  Whether a father, sister, or cousin, the family members took ownership of their loved ones lying in the hospital beds.  The language barrier was surpassed by Benon, the orthopaedic officer with us.  For the families, he translated post-op instructions, wound care instructions, follow-up plans, and answers to their questions.
Dr. Perry was the first one to mobilize her patients. We changed dressings and gave instructions to families regarding dressing changes, activity and pain management.  Cindy and Pam instructed the patients and families about wound care and gave them clean tegaderm and gauze we had brought. We passed out ibuprofen and Tylenol pre-packed in little baggies we had prepared. Trying to locate our patients was difficult as there were no patient rosters or room numbers. We continued to the ICU to visit a 12-year-old girl who had undergone a 6-hour spine surgery by Dr. Perry.  She stood up with Dr. Perry’s assistance and her posture was more upright and the kyphotic deformity was gone. As expected she was in pain but am sure she could envision a life of normal activity and posture. 

​   With all the surgeries being done under incredulous circumstances the team ventured to the wards to round on the post op patients. Most nurses and caregivers were on strike, so our challenges continued.  The general wards were divided into a male, female, and pediatric section.  When we entered the building, the concrete floors were covered with water with the morning cleaning crew sweeping the water across the surface to make them as clean as possible.  Blankets and food containers from overnight stays of the families lined the room surrounding the patient beds, which were about 18 inches apart.  Families were our biggest allies when rounding on their loved ones.  Whether a father, sister, or cousin, the family members took ownership of their loved ones lying in the hospital beds.  The language barrier was surpassed by Benon, the orthopaedic officer with us.  For the families, he translated post-op instructions, wound care instructions, follow-up plans, and answers to their questions.
Dr. Perry was the first one to mobilize her patients. We changed dressings and gave instructions to families regarding dressing changes, activity and pain management.  Cindy and Pam instructed the patients and families about wound care and gave them clean tegaderm and gauze we had brought. We passed out ibuprofen and Tylenol pre-packed in little baggies we had prepared. Trying to locate our patients was difficult as there were no patient rosters or room numbers. We continued to the ICU to visit a 12-year-old girl who had undergone a 6-hour spine surgery by Dr. Perry.  She stood up with Dr. Perry’s assistance and her posture was more upright and the kyphotic deformity was gone. As expected she was in pain but am sure she could envision a life of normal activity and posture. 

​We rummaged through the fabrics and shoes and jewelry and wandered in and out of the alley ways.  Almost ready to leave, we heard “Doctor, Doctor” coming from the street.  It was one of our patients who had just received an injection yesterday!  What are the chances??  Dr. Kotton stopped and she said she needed a prescription for physical therapy but had forgotten to get it yesterday.  He wrote the words “referral to physical therapy” on his business card and we bid her ado.
We returned to the hotel and a few people went to Lake Mburo to do some sight-seeing, but most stayed at the hotel to rest.  Dr. Perry had a meeting with the Dean of Mbarara University Professor Gertrude Kiwanuka who is a powerhouse leader for the University.  She also met with the International Health officer Sheila Niinye Olivia, and they brainstormed about ideas to build the program and relationship with the spine teams from the USA and Uganda.  Together we can build on an established relationship to make access to medical care continue beyond the week-long spine camps.
The day closed with everyone retiring to bed relatively early (except me writing this blog) in order to rise early at 3:30 AM to depart for our SAFARI!!!!!

​A power outage? Oh no! A medical strike and now a power outage, what more can go wrong, can this be remedied?  How can it be remedied and how quickly?  With five cases scheduled for the OR today we sat silently in a dark room waiting and praying for the power to be restored.  Please let there be light! Our prayers were answered as Dr. Kisitu informed Dr. Perry that the hospital generator was being connected to the operating room. What a relief!!! Did I say what else could go wrong? Well the good news is that we now have power in the OR, but the bad news is that we had no oxygen because the oxygen source was connected to power only.
There were no oxygen tanks for use in the entire hospital.  We all collectively sighed but Dr. Perry had this under control as she paid for oxygen tanks to be delivered from an outside facility. We were back on track or, so we thought.
Okay, so something else went wrong. Scrubbed and ready to go for the first case, which was a cervical decompression Dr. Perry and Dr. Barnard were suddenly informed that the newly purchased oxygen tanks were empty and once again a delay in the OR.  Frustrated the doctors removed their sterile gowns and caps and sat quietly wondering what else could delay this day in the OR and what they would tell their patients that have been waiting so long for their surgery.
Good news, good news! The tanks were not empty after all, they simply need to be unlocked appropriately. Nevertheless, the mishaps of the morning were water under the bridge and it was full speed ahead. Dr. Perry and Dr. Barnard scrubbed in once again and the first case began.

​Can I just say how excited I was when our scrub tech Andrea asked If I would like to be a circulator on the first case, this was my first trip ever into the OR and I was super excited.  YES! YES!! YES!!! My responsibility was limited to retrieving and opening a bottle of saline wash, but it was the most exciting experience ever second to being enthralled by what I was witnessing as Dr. Perry worked on the spine of the patient on the table.
Soothing music permeated the room as the doctors operated with laser focus, it was a tremendous sight to behold and an experience I would never forget.
With no clinic scheduled for the day, the OR was the center of our day and Dr. Ryan Kotton naturally stepped into the OR as second assist to Dr. Barnard on a lumbar case, while Dr. Perry began the third case a 14-year-old girl with a congenital deformity of her spine at L1/2 with an 80-degree kyphotic angulation.   Witnessing the precision and focus required for their craft in unreal and yet so real.  I was also able to see how integral both Andrea our scrub tech and Max our Medtronic rep were to the success of every case.

​Everything was going spectacularly, the lights came on and the generator was no longer needed to power the OR. About two hours later, the doctors were closing on the third case and OMG! The lights went off and the generator was no longer connected to the OR. Luckily the power outage only lasted a few seconds and the case was completed without issue.
Would you be shocked if I said the power went out for a fourth time? Well, it did but luckily Dr. Perry was closing on this patient and the RN Cindy jumped into action with the flashlight from her iphone to illumiante the area needed to finish the case, whew!! That was a close one.
                                                                    
With four power interuptions during surgery and oxygen running low, Dr. Perry decided that it was no longer safe to continue opearting, she  simply could not and would not compromise the safety of her patients and would need to pull the plug on the last case of the day.  Our 5th patient of the day was devasted about the news the her surgery was cancelled but her safety had to be priority number 1 above an elective procedure.
As an end of the day routine, the clinical team rounded to capture our post-op patients from the week despite the absence of a post surgical roster with their location. 
Technically, today was our last day in the OR as the rolling strike continues in Uganda. Without an anesthesiologist we can no longer operate ☹.  We tried to hire a private anesthesiologist and also asked for the chief resident to stay.  He was willing to do so, however, the powers that be of the Mbarara Anesthesia team did not approve that.
After such a challenging day, we all decided to have dinner at Café Havana to unwind, reflect and enjoy each others company.  Our dedication to serve our patients has been our number one priority since we arrived in Mbarara on Saturday and we have used enginuity to resolve setbacks both minor and major.  However, we must know when it is time to pull the plug. Dr. Perry’s lesson of the day was that she very rarely says “no” but she had to say “no” today to prevent catastrophe from happening on her OR table.  We were all extremely proud of her for the leadership she demonstrated and supported her decision 100%. 

​Anger isn’t the word, but disappointment, frustration and disillusionment might be more adequate words in terms of conveying the emotions our team feels today. It seems that a doctor’s strike was scheduled weeks ago, and we were only recently made aware of this information.  Essentially, the country has gone on a doctor’s strike and most health care workers have abandoned post. It’s been quite sad, luckily, we have an awesome team and have been staying until late at night sanitizing our own surgical supplies, buying meds for our patients and enticing doctors to say, unfortunately our efforts have been fruitless.

​Two days into the doctor’s strike coupled with an anticipated anesthesiology strike that would directly affect our ability to operate, the urgency of getting as many cases as possible on the docket is crystal clear.  With a lofty goal of 10 surgeries scheduled today there was no time for morning pleasantries as the physicians headed to the OR at 7am in hopes of helping as many patients as possible, there was no time to spare and it was all hands-on deck. 

​Simultaneously in the clinic setting, Dr. Ryan Kotton had a schedule filled with eager patients needing trigger point injections, corticosteroid injections and botox. However, a mini dilemma presented itself when we lost our translator Benon. With only two Lugandan words in our arsenal, noshasha (pain) and yoroba (relax) panic was about to take over when a very nice medical student walked into clinic in her search for another department.  Luckily for us she spoke English and she offered to assist, disaster averted!
Dr. Kotton was super excited to have this impressionable student in his clinic and he took full advantage of the opportunity to teach her how to evaluate imaging and techniques for administering injections.  What an amazing opportunity for this young student to learn from a world-renowned physician. 

​Have you ever been to a doctor’s office as an adult where you were offered a lollipop prior to getting a procedure done?  Well, you have never seen Dr. Ryan Kotton, his charismatic personality transcended culture in Mbarara as his patients simply fell in love with him. He offered them “special medicine” prior to the procedure and the smiles on the faces of our patients were priceless. In return he received hugs and deepest appreciation for changing their lives in a positive way. Everyone wanted to take a picture with him to show their appreciation, it was an amazing sight to see. If you saw a patient walking around Mbarara hospital with a sucker, you know for sure that they just saw Dr. Ryan Kotton 😊

​This image is one of true focus and determination, one that transcends the constrictions of social and political constraints. This is the focus of our leader demonstrating to her team that if we can think outside of the box, be resourceful, and work together we can accomplish great things for others. Today we finished nine out of the ten scheduled surgical cases, Dr. Perry was a Rockstar!! And again, that is not a biased opinion, simply one based in fact.

​The completion of 9 out of 10 cases was a remarkable accomplishment and the largest amount of surgical case any team has ever done. Fusions, discectomies, laminectomies, decompressions all successful from the surgical standpoint. It was an excruciatingly long day both clinically and surgically and we were not yet finished as all instrumentation needed to be washed, packed and sterilized before leaving the hospital. 
Who needs sleep? Surely not us! As the last case was being completed the team outside of the OR band together to wash instruments, pack them and prepare them for sterilization. As novices to this process we all watched the process intently and Dr. Socci, Pamela, Cindy and myself did what was necessary to make the day a success from beginning to end.
Can you say tired? Never has it been truer that a picture is worth a thousand words!!!!!!!!!!!!!!!!!!!!!!!

​After more than 12 hours of work, Dr. Perry and Dr. Kotton ordered us all dinner, we ate as a team, discussed our day and headed up to bed as we had another long day ahead of us on Wednesday.
***If you are ever in Mbarara Uganda, we strongly recommend Café Havana it’s delicious and a great big thank you to Dr. Tiffany Perry for teaching us that the Waze app works in virtually every country, your genius knows no limit 😊……… Good night, until tomorrow!

​It’s day 3 at the Ministry of Science and Technology in Mbarara, Uganda and we are loving the totality of this journey and all it encompasses. Witnessing the dynamism of the family unit in this country is nothing less than remarkable as families maintain constant vigil for their loved ones and friends accompany each other to appointments not out of obligation but compassion. Despite the systemic challenges faced by local Ugandans in terms of maintaining their own medical records in a notebook or waiting an entire day to be seen by a physician, the spirit of the people remains resilient and hopeful. The opportunity we have been given to be of service is priceless and even though we are here to serve the physical needs of this population, I believe that the people of Uganda have left an indelible imprint on each of us.

​Day 3 began with early morning rotations on the ward as Dr. Perry, Dr. Barnard and Dr. Kisitu evaluated many neurosurgery patients who required their expert diagnostic ability.
The ward overflowed with patients, but each received exemplary care from this team of dedicated and attentive physicians.  Dr. Perry and Dr. Barnard had 6 cases in the OR but let me just say that none of it would have been possible without our amazing scrub tech Andrea Searcy and our extremely resourceful Medtronic rep Max Yue who prepped each OR tray, cleaned and sterilized every instrument after each case. This team came to Mbarara to make a difference in the lives of patients, so with one autoclave machine, minimal outlets in the OR, extremely limited supplies and unimaginable politics these two stellar individuals overcame all obstacles and forged ahead.
Amazing job Andrea and Max, the two of you rock every single day!

​The spotlight shines brightly on our physical therapist Pam who worked in conjunction with the local Mbarara physiotherapy team to assess and provide treatment plans for our post -surgical patients as well as non -surgical patients who would benefit from PT. Quick assessment can turn into treatment that can improve patients’ quality of life. The beauty of physiotherapy is you can make big changes with minimal equipment and a lot of creativity. Working in a room with a chair and a table, Pam was able to address faulty body mechanics and provide basic home programs to allow them to continue to feel relief after they left. Pam’s treatment style is energetic and resourceful, showing the patients that their concerns were of the utmost importance. Most patients left laughing and dancing, which is one of the best medicines. Patients traveled from as far as Tanzania to see the team and one session of therapy can mean the difference between continuing to work to provide for their families or not. For the patients that live closer, they will be able to continue with the wonderful therapists at the hospital in the outpatient program. Pam’s spirited personality was infectious, and the patients simply loved her. 

 While traveling we always anticipate meeting new and interesting people and I would be remised if I did not mention Dr. Adrienne Socci, an assistant professor of Orthopaedics and Rehabilitation at Yale University.  Dr. Socci is currently on a reconnaissance mission at Mbarara hospital in anticipation of assembling her orthopedic team that would return to provide essential support and guidance to the staff here at the Mbarara University of Science and Technology.
                                                      
Dinner and reflection has become customary for our team at the end of the day, and according to Pam, “ Showing people that you care about their own unique circumstances is invaluable in helping them open up to you as a clinician and make positive change in their lives.” This seems to be a universal concept regardless of culture.

​Does anyone embrace the sound of an early morning alarm clock? I think it is safe to say very few, however, our very own Dr. Tiffany Perry began day 2 of our mission with a brisk early morning 4 mile run before meeting the team for breakfast at 6am. As for the rest of us, we hit the snooze button a couple of times, rolled over with pillows over our heads and prayed for an extra hour to sleep. Breakfast was served promptly at 6am as we had many patients anticipating our arrival by 8am.
The anticipation of our first official day at the hospital was palpable, how many patients would we see, what kind of cases would we encounter and how would we effectively communicate with patients who speak only the local language?
We began the day with some starting in the operating room and others starting in a busy clinic in the adjacent building

​The OR began with a T11-L3 posterior fusion for a traumatic L1 burst fracture for patient who was paraplegic.  The second patient was an engineer who had severe lumbar stenosis and underwent a lumbar decompression surgery. 
Hoards of patients lined up to see Pamela for physical therapy and Dr. Kotton for injections.  In between cases and after 2 cases were completed on the Sunday, we all combined forces to see over 100 patients!  Only in Uganda can we see that many in a day!  Examination rooms were filled with patients—sometimes more than one and their families.  The small rooms were humid and warm, and occasional rains intensified the air. With 4 providers seeing patients and our nurse Cindy and administrator Rhondine vigorously typing up summaries of each visit, plans were made for each patient.

​Our last patient walked thru the exam door at 7:15 PM.  We were exhausted, hungry and sweaty.  The evening closed with the traditional buffet dinner at the Lakeview Hotel.  Over dinner, we were able to laugh about the day and share feelings and thoughts about the hurdles we encountered that day.
The words of wisdom of the day came from Max Yue, our Medtronic rep: “Sterilization is a matter of opinion.”  We all took turns around the table after dinner, stating our lesson of the day.  Consensus was we are grateful for what we have, and our outlook when we return to our own practices will be changed forever.  We all retired to our rooms for a good night’s rest to be ready for a big day to follow.