The lessons of the day are a tradition in Uganda. It is the time after the meal when each person reflects on a lesson learned. We took pause that night as we reflected on the days experience and the experience we all had to process. Ninah’s procedure went without complication and the frustration of not obtaining a diagnosis is difficult to describe. Despite years of experience surgery can be a humbling experience. It is difficult to think of what good can come out of such an event. Dr. Burch spoke to team at the end of the night and reminded everyone that this seemed to be one of those random events, difficult to explain. The litany of potential causes for her low blood pressure had been ruled out and in the current setting without diagnostic imaging we would never know. He reminded us that we were a great team and in that darkest of moments remained confident we were there for purpose and the purpose could be met.

It was crystallized the next morning as our next patient was brought into the OR. She was a young seven year old with a severe deformity. As the films were pasted to the frosted window, which acts as a light box, the members of the team took pause. One by one they approached the patient who was scared of the clinical surroundings and odd sights and sounds so foreign to her. One of us held her hand and smiled. Another suggested a song to calm her. In a few moments the six of us were in chorus singing for this little girl letting her know the compassion and respect we had for her and for the procedure she was about to endure.

This was the rarest of moments when the silos are broken, where each member of the team becomes the team and the team becomes greater than the sum of the individuals. It was a time when the purpose of the mission became clear. It was a time when we all realized each of us had travelled great distances to bring knowledge, care and perspective to a remote region and an emerging nation. Despite the challenges of limited resources, limited equipment and the events of the day prior, our team was in unison more so than ever. We all had gained appreciation for what we were asking of ourselves and of our patients. The day’s surgeries went well and we finished early. Our second case, an elderly lady who came to us with lower extremity paralysis from a tumor in her thoracic spine also recovered well and began moving her legs. At home it is often difficult to visualize the essence of medicine as we each get buried under the scope of our responsibilities that force us to work as individuals. However, despite going to Uganda to teach all that we knew, the six of us that day gained as much as we gave. We gained the appreciation and privilege of what it’s like to be on a team working together with a common goal whose purpose is united and focused. 

The day started out just like any other day. It ended with an indescribable feeling of helplessness. 

Half of our team got up for the 5am run with our local running buddy, Joshua. The streets were quiet on this particular morning. The people of the city were just crawling into bed from the previous nights' celebration of the end of Ramadan(??).

We arrived at the hospital excited for another day of surgery and the challenges we would face. As we walked into the theatre we all noticed and eagerly waved hi to our first patient, Ninha. She looked the same as she did when we all first met her in clinic.. Beaming from ear to ear, curious and shy at the same time. Just the cutest. 

So much of spine surgery is algorithmic. Check the films, check the labs, check the levels, confirm the indications. Double check, triple check... Patients put their lives into the physicians hands and our team began this day realizing this privilege. The privilege begins as an opportunity to change people's lives, increase awareness of the possibilities in Ugandan hospitals and to spark innovation and change for the future here in Uganda. 

A complex operation ensued. The operation itself and the correction of Ninha's scoliosis went off without a hitch.

She then developed a complication.

All Nihna wanted was "to be better" 

The day speaks to the layers and layers of things we have at home in North America. We are so fortunate to be blessed with the care we all have. We take the type of healthcare we have at home for granted. This experience was both humbling and eye opening and crystallized the conditions by which the people of Uganda are forced to live. 

Life is short and very precious. Despite the best surgical care in the world it's earth shattering to imagine that something like this could happen to an 11 year old little girl.   

A 5am run with Joshua and then we boarded the shuttle bus by 7:15. We divided and conquered the morning rounds and the preparation for surgery. Promise was brought into the pre-op area of the OR, naked except for the brown blanket shrouding her. She sat on a stool alone in the little room as the anesthesiologist prepared for her case. He started to hum a Bantu lullaby, which seemed to calm her. All motion in the OR stopped as we took note of this simple gesture. As the anesthesiologist left the room to get supplies she became frightened. A hello from members of the team, a smile and then some drawing with Dani Thayer made her smile and put her at ease. It is the simple acts of unexpected compassion that restores faith in humanity and this is often the most powerful medicine. I was once told that “this is not something you learn in a book but it is something your mother teaches you”. Promise was comforted and began her six hours of surgery without complication that included a vertebral column resection and thoracoplasty to correct her spinal deformity.
 
Following surgery, the lost pallet of supplies to furnish our storeroom had arrived thanks to the unrelenting efforts of Errin Dalzell and the support network back home. While we unpacked the pallet, we continued to care for a friendly young woman, named Sharon, which we met during clinic on our first day. Sharon, a shy-eyed young woman with a beaming smile, visited the clinic with difficulty walking, weakness and loss of sensation in her arms and legs that had started several years ago.  At first glance, Sharon's condition had features common to spinal cord damage. Dr. Mimran observed that the cranial nerves that control neck and tongue movement were also abnormal, indicating brainstem compression. The review of the XRAY films revealed an anomaly in the highest cervical segment could account for the neurologic status. Due to the severity of this condition, the surgeons requested a CT films to corroborate their finding definitively and to develop a surgical plan. Sharon and her family did not have the resources to obtain these films, so HVO arranged for the funds and transportation on her behalf. It was also decided that a member of the team 2 should accompany her to ensure that correct films were obtained, expeditiously. J.P. Clark, the neurophysiologist of group 2, escorted Sharon and her sister, Hope, in the team bus, to an offsite private imaging facility in contrast to Mbarara University Hospital where the CT scanner was in a state of disrepair. The CT scan was uneventful but the trip provided the CT scans necessary for Dr. Mimran to confirm that the cervical spine was entering the skull and likely accounted for the brainstem issues. Dr. Burch and Mimran decided that the surgery would require a head and neck surgeon to provide access to the anterior spine through the mouth and would require a transoral approach. Considering the need for this expertise along with the high risk of the spine surgery, they felt that the surgery could not be performed safely in Uganda.

The surgeons met with Hope and Sharon and discussed Sharon's diagnosis.  

The news was disappointing for them not only because they could not get the surgical care they had wished for but considering what was required, there was little hope for surgical care in the future. After a moment to digest the news, Sharon beamed again and expressed her gratitude for the diagnosis and the kindness and compassion our group provided.