My head felt like it just hit the pillow when the alarm rang at 6AM this morning.  After almost making the intestinally devastating mistake of brushing my teeth with tap water, I showered using the broken hand held shower and ambled downstairs. Today was another big day for the spine team and it started off with our now standard breakfast at the hotel – pale scrambled eggs, sausage, sweet bread, potatoes, coffee, and some of the most delicious pineapple I've ever had.   Washed all down with Ugandan coffee and a desert of Malerone anitmalarial medication.  We headed into the hospital planning to do one "smaller" case first followed by a multilevel scoliosis case.   As soon as we hit the OR at 7:30, we had to go into immediate trouble shooting mode. 

Our cases had been switched without our knowledge and the scoliosis case was going first.   The instruments we required for both cases had not been autoclaved to sterilize them because the power was down and the OR autoclave machine would not work.  To top it off we didn't have an electrocautery pad (essential to reduce blood loss).  These obstacles aren't even considerations in the States but fortunately we had Brian and Sherron on the team.  These two set the standard for team work.   While they got to work, Dr. St Clair and I (Eric) began rounds and got a chance to see Eziekel sitting up in bed smiling.  He was doing great, a bed over from him was Mary who was quiet but wanly smiled with those trusting eyes.  Brian somehow found an autoclave in another building and managed to get the job done.  Sherron worked her magic and located another bovie pad, hooked it up, and after a brief delay we were ready to go.  Our first case was Shakira, a little 10 year old girl with progressive juvenile idiopathic scoliosis who was brought in by her concerned father from an outlying village. 

Dr. St Clair sent me over to help Dr. Kip position the child and obtain the surgical exposure.  As I have moved through this task, Drs. Kip and St Clair have helped me continually advance my surgical skill set. Today Dr. Kip and I each exposed a side of the spine and I identified the relative anatomy key for placing instrumentation.  Dr. St Clair joined us and we efficiently moved through the case.   Throughout the case we had Mbarara nursing and medical students come to observe and it was Sherron's hawk-like eyes that protected the equipment from being contaminated and kept the patient safe by reminding them to pull their surgical masks over their noses.  We placed our pedicle screws (screws that hold the rods we used to correct the deformity), performed ponte osteomties (technique to remove part of the "back" of spine in order to mobilize it for correction), and then corrected the deformity maneuvering the rods to "straighten" the spine.  That's a one-sentence summation of an incredibly detailed operation.  There are numerous technical pearls I gleaned from each case, but in a more general sense I appreciated Drs. St Clair and Kip's mastery of the anatomy and how they used subtle variations to direct each step of the operation.   We completed the case and were gratified to see the child move all of her limbs.

Under Sherron's guidance we helped sterilize the room and got our next patient, Gardenisia, into the room.  Gardenisia is a 60 year old local villager who unfortunately has a cancer of unknown origin with a tumor that was compressing her spinal cord.  Starting at about 9:15PM we were able to debulk her tumor, decompress her nerves, and place instrumentation to stabilize the spine.  We finished, cleaned up the room and headed back to the hotel for another midnight meal.  We ate in a haze of exhaustion but with a deep feeling of satisfaction.  Throughout the day the concept of teamwork, which has defined this mission, seemed to be in continuous display.  Not just among the members of Spine mission Uganda team, but the hospital staff in general.   

Andrew and Emmanuel the anesthesiologists willingly stayed late and ensured every patient moved through the OR to ICU with the care each one deserved.  Sister Rose, the nurse manager of the OR was essential to orchestrating each case and was essential in Brian's epic quest to find the autoclave.  Florence, one the OR cleaners, who had no reason to go above and beyond her job duties, tirelessly worked with us and ensured all of equipment was available.  And Marvin our resident surgeon / goat herder extraordinaire who made sure all of orders made it to the right place and somehow tracked our patients down in remote villages were all essential to our success.  Both the Ugandan and American teams learned how to function as a unit and this bedrock was essential to our patient's outcomes. 

Quote of the day:  “Mbarara at night reminds me of San Francisco.” – an exhausted Eric gazing at the town’s hillside lights at night.

This morning and last night seem to be so close together that the were almost continuous. We got to bed around 12:30AM, out of bed at 6:00 and we left for the hotel at 7:15 in order to get to the hospital and prep for a surgery that would start roughly around 8. The first patient of the day was Beatrice, a 59 year old woman with significant lumbar stenosis (narrowing of the spinal canal with compression of spinal cord).  We preformed L4/L5 lumbar lamonectomies (removing a portion of the “back” side of vertebrae to free up the spinal canal), the case went well and the patient left mumbling her gratitude on the way out of the OR. The next patient was Mary Glumoshare, a orphaned 14 year old girl with severe congenital scoliosis.  Mary's life has not been an easy one, the difficulty faced by any orphan in the third is unimaginable.  This is compounded by an obvious physical deformity that can make them a target for bullying.  We all collected as a team, prepped the patient and said a prayer.  Mary is a quiet, sweet child with eyes that stare right through you.  

Serendipitously, Mary's last name means "glory to god" and our anesthesiologist decided today was going to be the day he rocked out to Christian rock music for duration of the 6+ hour case.  We were able to significantly correct her deformity and instrumented her T6 to L3 vertebrae with a hemivertebrectomy (removing half of a vertebra) at T11.  This was no easy task for Dr. St Clair, Dr. Kip and Dr. Varley who made the case flow by with an air of calm focus. It was another late night for us but it was all worth our efforts because the surgery went very well.  After cleaning up the OR and getting prepared for tomorrow we checked in on Mary who was neurologically intact and on the road to a great recovery. 

I noticed a Mbarara University surgery resident, Marvin, who was constantly working hard and had a happy demeanor about him. I found myself having a deep conversation with him during a brief break in between surgeries.  I told him how impressed I was with his work ethic and it lead to him telling about himself. He was truly so humble yet confident when explained to me "Life in Uganda is hard and you have to work hard to survive". You see Marvin used to be a farmer, well, he still is a farmer; that's how he supports himself through residency in addition to his work here at the hospital. I asked what kind of farm do you have and his response was "It is very little, I only have thirty goats and three cows". Blown away by this statement I could only tell him how impressive that is to someone like me. Someone who's standards of working hard don't hold a candle to Marvin's. The people that live in Uganda have so little and work so hard for what little they have it is hard to comprehend.

We wrapped again around 11:30pm. Had a group dinner this time at the Agip Restaurant and Hasan, our tireless driver, dined with us.  Dr. St Clair preordered for the team.  He is always thinking ahead and taking care of the team.  After a relaxed dinner, it was midnight we agreed we were turning into pumpkins.  We hopped aboard our favorite travel bus and headed back to our temporary home.  Another good day under our belts.

Quote of the day: If you don’t respect your work, then people won’t respect you.  Marvin, on the Ugandan work ethic.

Today was the first long day of surgeries, but certainly not the last. We had one major congenital scoliosis case and a lumbar stenosis (narrowing of the spinal canal with compression of the spinal cord) case. 

Our first case was a 9 year old boy name Eziekel whose about the most positive little human being you've ever met.  He was a little nervous entering the OR but Joan (my Mom) helped calm his nerves with some coloring.  Drs. Kip, St. Clair and Varley worked tirelessly and flaw lessly, with the support of the team, to perform a T6-L3 posterior instrumented fusion with a T10 hemi-vertebrectomy. This 7 hour surgery demanded all hands on deck.  On the onset of the case we faced a C-arm (intraoperative xray machine) that is critical to determine which vertebrae to instrument.  After making a substantial payment, this unit had just been fixed but now we had no idea why it wouldn't turn on.  Brain Failla, our Globus Surgical Rep/ X-ray technician / circulator/ sterilization / handy man attacked this problem and discovered that someone had unplugged a cable within the storage battery likely looking for another substantial payment to fix it.   A quick plug in and the C arm fired up like a dream.  The case was truly a collective effort all the way through.  At one point, Chris Martin, our neuro monitoring guy, caught a slip up that may have resulted in a major consequence - nerve compression resulting in a foot drop.  When the patient became light on the table, due to anesthesia wearing off, he kicked his leg off and due to the drape covering him no one noticed. Chris's monitoring promptly detected this and we avoided what could have been a devastating injury to the patient.  Joan, my fellow volunteer and mother, was busily filtering through the totes of medical supplies organizing the antibiotics, dressings, suture, gloves, braces, etc. in the storage room making it efficiently locate needed supplies straight away. 

Sherron, our registered nurse, was expertly scrubbing with the doctors in the OR and assisting throughout the procedure. As for myself, I was given the opportunity to shadow Eric Varley, PGY 3 orthopaedic resident.  I round with him in the mornings.  My backpack has been functioning as a mobile medical unit stuffed with dressings, tape, antibiotics, gloves, scissors-  and  don't forget the hand sanitizer.  Also, I kept track of all patient X rays.  Eric has taught me to be methodical, accurate, and conscientious.  He has driven the point home that years from now when our records are reviewed, everything must be legible, organized, and consistent-or all is lost.  He is a wonderful example of all of those traits- and also a natural born teacher and now a great friend.   Our team has blended naturally to become the seamless surgical machine it is.

Our second case was Musa, a 68 year old man with lumbar stenosis, epidural tumor and prostate cancer.   We began the case with Dr. Kip while Dr. St Clair and Dr. Varley attended to the patella fracture we saw in the wards a day ago.  Musa had multiple issues resulting from his undiagnosed prostate cancer which had spread to most of his spine.  He needed a spinal tumor mass debulking, decompression of his spinal canal and instrumented fusion from T10-L1 following this ordeal the general surgeons came and performed an orchiectomy, yikes!  Needless to say it was a much tougher day for Musa then any of us. Again the team came together in spectacular manner in order to overcome the obstacles that Ugandan hospitals pose and help this seriously sick man. 

Meanwhile, in OR 3, Dr. Varley and Dr. St Clair were operating on Julius, the 45 year old man who had a comminuted patellar fracture, courtesy of-you guessed it- a boda boda accident.  After copious irrigation, Drs. St Clair and Varley repaired it with heavy sutures and repaired the damage to his knee joint capsule.  Usually, or so I've learned, you have to keep the patients leg straight in a full leg knee immobilizer.   Unfortunately, we didn't have one so as the surgeons worked I was tasked with heavily taping straight a hinged knee brace.   The surgery went excellent though hot (there was on AC in this OR) and one of the Ugandan residents, our man Marvin, learned how to manage such an open injury.  It was fascinating and saddening to hear that this type of injury usually requires an amputation and possibly death from a blood infection.  It was again a reminder how important this work is and how gratified Marvin felt to learn how to manage such an injury.

Monday was a great day.  We all really bonded as a team and were working together very well to serve the patients of lovely battered Mbarara.  We left the hospital and arrived for a late night group dinner, where, Dr. St Clair reminded us of Dr. Lieberman's tradition of going around the table to hear each person share lessons they learned from the day.  Each perspective was unique and insightful.  We have repeated this tradition as the days have gone on and it is absolutely amazing how much has changed for us.  Our investment in this place, respect for the people, and future plans to return continues to grow each day.  We finished dinner just after midnight, after another rewarding, great day.

Quote of the day: He just made alittle incision, grabbed them, and pluu-mp! - Brian describing the orchiectomy he walked in on.