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. 

Today  was a day of extremes.  Unfortunately, we were unable to operate on Sunday so we headed in early to get rounding done on the patients from the previous week.   We walked into the ICU and were happy to see one of our patients Eric Agaba, who had undergone an extensive staged spinal fusion for tuberculosis induced spinal deformity, had been moved to the general wards and was slowly improving.   We were again struck by the lack of resources and difficulty in what we consider to be basic care.  This was illustrated by the lack of simple IV antibiotics and steroids - we had to both provide the medications and the nurses with detailed instructions on how to administer them.  We then moved to the surgical ward which had mercifully been thoroughly cleaned and the patients were listening to a Sunday sermon.  We were immediately greeted by extreme tragedy and celebration.  We got to give fist bumps and hugs to "Frank the Tank" as he headed out to return home.  The joy radiating from this little guy could of lit up the room.   As we were leaving Frank, a  frightened looking mother approached the team asking if we could look at her daughter who had fallen off the back end of a pick up truck 4 days ago.  The mother was accompanied by her other daughter who explained that her sister was heading back to University and seemed not to be doing well. The concern and fear reflected in both of their eyes was undeniable; Dr. Kip and I (Eric) agreed to see her and went to the patient's bedside.   The patient was breathing extremely rapidly and moaning in pain with her leg wrapped in a blood soaked bandage.  The mother immediately handed us the x-rays and explained that her daughter's femur (thigh bone) had been sticking out of her skin after the accident.  The x-rays made our stomachs drop, she had completely fractured both her femur above her knee and her tibia (shin bone) below her knee.  She essentially had an floating knee and was breathing rapidly due to either loss of blood or a blood clot in her lungs.  The overwhelmed intern who admitted her had only wrapped her leg up in a gauze dressing.   Now, 4 days later, she had lost alot of blood, potentially had a blood clot in her lungs, and was in severe respiratory distress.  We immediately sprang into action, Dr. St Clair went to get the patient emergently moved to the ICU.  We looked at this 20 year old girl who had beaten the odds, was attending university with a proud family and potentially bright future in a country where  hopelessness was so common place and prayed as we got to work.  

Dr. St Clair was confronted by the ED physician, who was about to do a bedside craniotomy, and was informed that it violated protocol.  After some convincing he said it would be ok to move her but apparently there was no oxygen available in the ICU.  We were then informed that we could buy it ourselves for 80,000 schillings (about 35 dollars).  Dr. St Clair quickly agreed, sadly while we were jumping through these hoops the patient quit breathing and we were unable to resuscitate her.  Instead of a bright future at university she died today from an injury that would of been surgically fixed with her already discharged if we had known about her 4 days ago.  The sister just looked at me and said in a statement of tragic acceptance that her sister was dead.  To compound this tragedy she was also pregnant.  Everyone on the Team, newbies like me to veterans were devastated by this news.  Part of medical training is learning how to steel yourself against tragedy, to feel and acknowledge it but not to let it dominate you.   In the moments following this senseless tragedy we were all wide eyed and grief stricken as we chorused how this shouldn't have happened, how painfully unnecessary this was, and how we could have saved her if only there had been more time.  Her name was Onvia, instead of a bright future at the local university, she suffered and slowly died from a treatable injury in front of her agonizing family.   I am sure this is difficult to read and I assure you it is difficult to write.  I imagine those of you following this blog are asking why, why did this have to happen.  There are no easy answers.   This is a medical system that is overwhelmed with scarce resources and protocols that can prevent rather than facilitate care.  In a country where the population lives with the reality that one "big hit" such as a fracture is more often than not a life-ending event.  To me it is a unforgettable reminder of the dire need for expanding medical mission trips to serve those like Oniva who deserve a chance at a bright future. 

After leaving the hospital, we talked over some of these points in a vain attempt to bring understanding to how we were feeling.  Our morning was over, we decided to continue with our plans to use our only free afternoon to drive to Queen Elizabeth's park and go on safari.   As we slowly moved out of Mbarara, the land became unbelievably lush with such vibrant shades of green you'd swear it w as from some special effects driven movie.  We didn't talk much, the rolling hills, lush landscape, and clean smelling air slowly helped us let go of our collective hurt and move forward.  After 2 hours of driving, with a level of road disrepair that made us long for our ride from the airport, we finished climbing a mountainside, rounded a corner, and lost our collective breath.    

Extending into the horizon in valley below us was the savannah of Queen Elizabeth's park (second biggest park in Uganda).  Imagine whatever picturesque view of the African savannah you might have and I assure you it would exceed it.  We pulled over, stretched, shot some pictures and inhaled the sweet counterpoint of Uganda's unmatched beauty.  We enthusiastically clamored aboard our vintage suspension free bus and headed down into the savannah.  The next few hours were unforgettable: Brian frolicked with a friendly baboon, we saw a hippo and elephant moving through the bush, numerous antelope, and got to experience off-roading in our team van.   The undisputed epic moment of the trip was watching a leopard lay out and groom itself 15 feet away from us.  A sight that is apparently so rare that even our guide had to stop and take a few pictures. 

As we road back to the hotel in a collective exhausted daze, I couldn't help but reflect on how we had all been taken through the full range of emotions.  And perhaps this typifies the Spine Mission Uganda experience: there is so much that is awe-strikingly beautiful and gives you hope and there is so much despair and hopelessness.   Ultimately, I believe those who participate have a profound feeling of gratitude for the experience and a drive to expand our mission to help those who need our help the most. 

Quote of the day: I wish I had a tiny saddle - spoken by Austin as he watched Brian interact with the baboon.

For our first day on our own, team three hit the ground running, and without the guidance of team two it was time to step up. The team felt much more rested after a good night's sleep and nourished by a hardy breakfast. Except for me (Austin), due to unwittingly taking the fastest acting laxative known to medicine or lore, the Indian Chicken Palaka.  Aside from my bothersome  GI issues, we were firing on all cylinders today.  We had a scheduled OR start time of 0800, but had assumed that the OR would be running on usual "African time" with a likely start time of 0930. This ,dear reader, was our first mistake.  We arrived to the OR nurse stating flatly "You're late".  Surprised and scrambling we got the morning rolling quickly from there.  We put on our efficiency hats and divided up  ---- Doctors St. Clair and Kip  heading to the OR for a lumbar decompression with the assistance of Sheeron and Brian.  For Eric, Joan and I it was time for rounds. These my friends were no ordinary rounds. Right from the get go we were hindered by basic equipment breakdowns, such as leaky oxygen tanks, which Eric MacGyvered .  It was this kind of ingenuity that allowed us to make forward progress at all.

The conditions were unbelievable. It was clear the staff was trying to manage the patient load, but were running into overwhelming road blocks.  The ICU had 3 of our patients such as Eric Agaba - our respiratory distress patient who was doing much better but taking no narcotics- after a massive two stage congenital scoliosis correction surgery.  The patients' vitals and lab data required half an hour of searching and were only partially available.  Overall, our ICU patients all seemed to be improving.  We did multiple dressing changes and assessed our patients but there wasn't much we could do to minimize their pain beyond showing that we cared with a gentle touch and encouragement.   The Ugandan staff as well as some of the patients live in fear of forming addiction to pain medications and are extremely reluctant to use them. 

We finished up in the ICU and headed to the wards. This was like nothing I had ever experienced; the patients were packed into large open rooms with a male and female ward on either side of the building.  The lighting was relatively non-existent and the insects were everywhere.  The final component was the smell - even writing this I can't quite shake the odor - it was a mix of infection, excrement, blood, and severe body odor.  Fortunately, even in this difficult situation there were definite rays of hope.  Each patient had family surrounding them and doing their best to care for them.  Our little girl Promise was out of the ICU today with improving function in her legs.  We also saw 14 year old Mary with severe scoliosis.  We couldn't believe this pretty little girl was 14.  Because of her small stature, we thought she was somewhere between 6 and 8 years old.   Mary is also an orphan and life has not been kind to her.  Unfortunately, due to the severity of her deformity it can make her a target for bullying.  We reassured Mary that we were going to do our best and We finished up rounds and met the rest of the team in the operating theater to get our supplies further organized and prepped for tomorrow.  We also saw another patient randomly in the halls and reassured him that his mild neck pain was a normal part of having a cervical spine fusion.  On our way out the door a nervous looking intern approach us and asked if Eric could glance at his knee.  Eric agreed and saw that the patient a severe open patella fracture with bone sticking out of the skin, the intern wasn't sure if he should just put gauze on it and leave it.  Eric quickly educated him on the nature of open fractures, as we left the wound was being irrigated, antibiotics were started, and we boarded him for surgery early next week.

After concluding our time at the hospital we headed back to the hotel where we witnessed a Ugandan wedding reception in progress.  The women wore the most vibrant dresses I've ever seen and the air of festivity was a sharp counterpoint to our experiences in the wards.   Dr. St Clair also regaled us with some of the details of the Ugandan wedding rituals over beers.   Apparently, the groom gets "roasted" by a designated member of the bridal party - who tells all manner of insults to prompt the grooms family to bestow gifts upon him until he feels that the brides worth has been met.  We all agreed that this was awesome tradition and would make for much more entertaining weddings stateside.  We then climbed aboard the bus and were off to the Nakumattmbarara market - a clearing house of all random home goods that is reminiscent of a Target.  Stocked up on water, coffee, and a couple bottles of spirits, we headed back to the hotel.   At this point we were all fading and in need of catching up on our rest so back to the hotel we went. 

After a brief siesta, we met again for dinner at the Rhino Restaurant at our hotel.  Dr. St Clair led us in a Lieberman tradition of going around the table and discussing what we learned today.   For me, the learning experience was an invaluable and overwhelming epiphany of how real it is for these destitute people. I had watched videos and read about how the terrible conditions are in Africa but seeing this first hand literally rendered me speechless. I wasn't sure what to do at first, part of me wanted to run, part of me wanted to cry and part of me wanted to just start hugging them. I have now had some time to digest what I saw, but what I realized is I will never empathize with their suffering. It is incomprehensible for me. I am so blessed and lucky enough to even have the opportunity to be here.  I offer my help more as a symbolic token now because I could never truly alleviate their hurting, but we on team three will give it our best damn shot.   For me, Eric, I also recognized just how much we take for granted in healthcare back in the US.  Our team rounds were like nothing I've ever experienced, almost every encounter required obstacles to overcome and necessitated creativity and problem solving.   For instance, availability of exam gloves, getting vital signs, or just communicating all required making do.  The amazing thing was despite difficult conditions, the patients were grateful to be there and that gratitude couldn't help but elevate you.  Recognizing this gratitude and using every mental as well physical resource to problem solve were invaluable lessons for today.  After finishing our debriefing we enjoyed an epic meal of delicious local talpia and wine.  And yes, my (Austin) stomach system held up and I am feeling both gastrointestinally comfortable and ready for sleep.  We rounded out dinner and sleepily made our way upstairs to get ready for tomorrow.