Today was our last “big day” with Dr. St Clair and we were all determined to make it a good one.  After another 5 hours of sleep, the team assembled downstairs for breakfast.  To any observer it was plain to see that we were tired but also that we were focused on making today a success.  We headed to the hospital for a 7:30AM start for our first case, Jadrass is a 54 year old man with severe L3-5 stenosis and weakness of his left leg which makes it difficult for him to walk more than across a room.  For this case the tireless Mbarara surgical resident Marvin was nominated to work alone alongside Dr. St Clair and get one-on-one education on the surgical technique.  Marvin was excited to be in this position and Dr. Kip, Austin, Joan, and I (Eric) headed out to round.  We were focused on making progress with all of patients this morning.   In the American healthcare delivery system if you order an antibiotic be given, a blood draw for a lab, or order physical therapy to walk with the patient you can generally count on it happening.  This is not true with the Ugandan system, we learned that unless one of us was there to physically witness or assist in whatever order we requested there was maybe a 50% chance of it getting done.  This problem is often compounded by the patients themselves who will deny receiving a medication that they’ve already taken in hopes that another dose will make the treatment more effective.  As we moved through our morning rounds we recognized as the final mission team that part of our service was to ensure consistent progress towards discharge.    

For some patients such as Eziekel this was as simple as removing his bulb drain, for others such as Denise (who was on a ventilator) this was more difficult.  We took time to demonstrate to the physical therapist how to mobilize each patient and it was incredibly gratifying to see some of patients take their first post-surgical steps with Dr. Kip.  In addition to our medical care, Joan (Team 3’s caring volunteer) gave her time to encourage the children and hand out Pillow Pet stuffed animals which all of the children enthusiastically expressed their gratitude.  Witnessing the joy this brought them reinforced how important and appreciated these simple acts of kindness are in a patient’s recovery regardless of how potentially overwhelming their clinical obstacles.  

We completed rounds and headed to the OR where Dr. St Clair and Marvin had just finished up.  Marvin was rightfully proud of their case and kept repeating just how much he learned from the experience.   Which was a good thing because for the second case we placed him across from me as I instructed him on the surgical technique to expose his side of the patient’s spine.  Our final major scoliosis case was Sarah, another adorable 8 year old orphan who was born with a defect in how her vertebrae were formed.  Sarah had an extra half of a vertebra (hemivertebra) that was shaped kind of like a triangle and a partial autofusion of two other vertebra resulting in a significant deformity.  As I worked with Marvin on the initial exposure of the spine, I reflected on how much I had learned and how fulfilling it was to share that knowledge with Marvin.  The old adage “see one, do one, teach one” was exemplified on this mission as we moved efficiently through the case.  Drs. St Clair and Kip progressed smoothly through the case, removing the hemivertebra while maintaining careful control not to damage the fragile nerves.  The case went wonderfully and Sarah was able move all of her extremities afterwards.  The case lasted until late in evening, as we finished cleaning up Sherron (our tireless nurse/scrub tech) remarked that though she had never had one in her life, tonight she needed to unwind with a Nile lager    

We all couldn’t have agreed more and headed to the bus, exhausted but riding high.  We made our way back to the hotel and sat around enjoying dinner and each others company.  Sadly this was Dr. St Clair’s last night with us and we all went around the table discussing what we learned.  The mission had touched all of us in profoundly indelible ways.  Perhaps one of the most memorable speeches came from Martin who spoke on what a privilege it was to work with the team and remarked on all that he had learned.  He reminded us that the mission not only helped patients but that what the Mbarara physicians and staff had gained would help numerous patients to come.  Dr. St Clair concluded that the privilege was truly ours and we headed to bed feeling accomplished and grateful for having completed our final large case. 

Quote of the day: We are actually done, that’s it… I need a Nile. – Sherron.

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.