Day 10

We couldn't believe it was already Saturday. Our last day in the operating room had crept up on us so quickly. We had only one surgery scheduled for today, however if had the potential to be a substantial case.  16 year-old Sheila has spastic cerebral palsy, a neurological disorder caused by injury to the brain in the perinatal period leaving her non-communicative and non-ambulatory. As a result, her body is tightly curled into the fetal position due to the imbalance between her flexor and extensor muscles.  Because of this muscle imbalance, her spine has developed a severe deformity making it near impossible for her mother to provide care and personal hygiene, and rendering her unable to sit up even with a brace or some form of support.  Sheila's mother carries her daughter draped over her arms. The girl is grotesquely undernourished, a clear sign that feeding her is difficult. Finally, Sheila is in constant pain as manifest by her heartbreaking wail. 

While Sheila will never regain the use of her muscles, nor will she ever walk, Dr. Lieberman could still use metal screws and wires to reduce the curve in her spine and to allow her to sit upright. This would tremendously reduce her mother's burden as caregiver. It might also even help with some of Sheila's pain.

Our morning got off to a good start; we were even ahead of schedule... until Zvi jinxed us by commenting on just that. Within five minutes the entire hospital lost power, delaying our start time. Power returned to the operating rooms within half an hour but the rest of the hospital was still in the dark. The head nurse of the surgical ward even borrowed an outlet in our operating room to boil eggs for her lunch.

Sheila's operation took almost 5 hours. As Dr. Lieberman revealed the spinous processes of Sheila's spine (the parts the form the bumps under your skin), he made an unfortunate discovery. Because she is unable to bear weight and likely deficient in vitamin D, Sheila's bone was very soft.  Worse yet, it wasn't clear that her soft bone could withstand the pressure of the metal wires even after she had healed. Past the point of no return, Dr. Lieberman finished the surgery and Sheila was sent to the ICU.

Sheila's case exemplified some of the ethical dilemmas in surgery, and so our lesson of the day revolved around her. Unlike our other cases from this week, Sheila's operation was not expected to provide significant symptomatic relief. When I asked Dr. Lieberman what the goal of surgery was, he explained that sometimes you have to adopt a perspective that includes the suffering of the patient's family. In Sheila's case, her mother was unable to properly care for her in her current state. Perhaps a straighter spine would allow Sheila to prop herself up and eat, thus improving both her and her mother's quality of life.

Having just completed our last surgery, the team packed up the operating room and stored our equipment for pick-up the next day. After rounding on some of our patients, we left the hospital for our final dinner in Mbarara. We were joined by Dr. Joseph, a surgical trainee at the hospital, and by our trusted middle man, Metu, who takes care of all the shipping and receiving for the mission. Back at the hotel later that evening, the team sat with a bottle of wine and some beers and reflected on a very productive and rewarding week. We shuffled off to bed, each one wishing this had not been our last operating day.

Day 11
Move out day. After a leisurely breakfast at the hotel, Izzy, Zvi, Rob and Dani left for the hospital for a final review of the patients. There they met with Dr. Deo and Dr. Joeseph and as a team changed all the dressings, pulled all the catheters, and provided last minute therapy and discharge instructions.  At the hospital, Rob immediately began retrieving our equipment from storage and loading it with Mr. Metu and his team onto the delivery truck. When all packed, the four made their way back to the hotel to meet up with Sherri and Jen. The six of us then loaded our luggage onto the truck and started the nearly eight hour drive back to Entebbe.

Along the way, we stopped at Lake Mboro National Game Reserve. We spent over two hours driving though the park, taking photos of zebras, warthogs, monkeys, and other indigenous wildlife. It was our first and only tourist experience inside Uganda!

We made it to Entebbe eight hours later with numb bottoms and empty stomachs. In our usual fashion, we discussed the lessons of the day over dinner at the hotel.

With the long drive back to Entebbe to reflect on my experience on the Mission, I realized I had witnessed some of the best leadership and team building skills I have seen yet. Dr. Lieberman is as natural a leader as they come, and from watching him and his surgical team over the past week, I recognized the skills that make an effective team leader: expertise that commands respect; teaching methods that drive pupils to want to know more; organizational skills and the ability to coordinate a network of moving parts; setting an example of patience and perseverance in the face of challenges and setbacks; encouraging team members to reflect on their own learning and their roles within the team; and finally, the acuity to select members of team that have their own expert skill sets and personality types that mesh together naturally. That was one of the most valuable and translatable lessons I learned during my two weeks with the Uganda Spine Surgery Mission.

So that's it! Time to sign off. Tomorrow the team flies back to London and then on to our respective home cities. It was a privilege to be part of the 2013 Spine Surgery Mission, and I look forward to hearing about all the successes of the 2014 trip!

Quotes of the day:

"We still have a wottle of bine"

"Six numb bums"

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.

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.

Ida, 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!

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.”

 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.

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.

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).

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 7Our 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!

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!

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).

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.