​The next day, we went to the hospital one last time to round on our patients before taking the bus to Entebbe, where many of us began the trip back home.

​Priscilla (our scoliosis patient who had surgery Wednesday) is recovering well and standing up straight. The pain tolerance and determination of many of our patients in Uganda has been astounding. None of them have had any IV pain medications post-operatively, yet most are up and about the first day after surgery.
 
On the bus ride back to Entebbe, we took a scenic shortcut to avoid “jam” (which is what they call traffic in Uganda). Not only did we shave an hour or so off of the 6-hour drive, we also were treated to some nice views of the countryside.

​Megan: “Are there any liquor stores around here?”
 
We stopped by the equator line on the way to Entebbe for coffee and pictures. They have an interesting set up at the equator line with three bowls: one in the northern hemisphere, one on the equator line, and one in the southern hemisphere – all three no more than 10 feet away from one another. When water is allowed to drain from each of the bowls, the resulting water funnel twists in opposite directions on the north vs. the south side, while the water draining from the bowl directly on the equator line doesn’t seem to spin at all. A bit hard to believe at first, but we saw it with our own eyes, and even switched the bowls around to be sure it wasn’t a trick.
 

​ 
With that, the trip – and the blog - have come to an end. This mission has been a unique and transformative experience for me in many ways, and I have taken from Uganda many lessons and memories that will surely stay with me for the rest of my life.
 
As a special sign off, we leave you with a fantastic video that Michelle has put together to chronicle the July 2016 Mission.
 
Wishing everyone in Uganda and elsewhere a safe and happy year. Thank you to the many people who came together to make this trip possible.
 
https://www.youtube.com/watch?v=262wUxLGBeI&feature=youtu.be
 

Today is the final operative day of the mission, and we intend to sprint through the finish line. The hospital graciously allowed us to use two O.R. rooms today, as we have 5 operative cases that we hope to finish before we leave. Everyone buckled down and really came together to get things done today.
 
The surgeries for the day included: two anterior cervical discectomies and fusions (one for degenerative disease and radiculopathy and the other for trauma) and three lumbar decompressions and fusions for adult degenerative spine disease. Much of the equipment had to be run back and forth between the rooms during the cases, as we didn’t have enough C-arms, bovies and drills to run both rooms simultaneously.

​After the operative cases were done, we still had to pack most of our equipment back into tubs to take with us to the warehouse for storage or back to the states to the companies and individuals from whom we had borrow them. Luckily, Lance is a beast, and had cleaned and packed most of the instruments and other equipment before we were even done operating.

​Our last night in the Mbarara O.R.
 
Exhausted, we made it back to the hotel in time for dinner and packing up our luggage. 

​The big operative case of the day was a young lady named Priscilla who had idiopathic scoliosis. Priscilla is a nursing student in her final few months of nursing school. She has been trying for years to visit our mission and have surgery, but because of issues with timing, she has never had the opportunity to have her deformity corrected. This year, the stars aligned and we were able to see Priscilla and schedule her for surgery. This meant that she would have to take a leave of absence from school for several months, and although this would set her back a bit in the process of becoming a nurse, she did not want to let the chance slip away again. We spent the morning and early afternoon correcting her deformity and fusing her spine into a new, straighter position. 

​Our second patient was a young lady named Jolly who presented with back and leg pain. She was found to have fractures and erosion at L2-L3; the appearance was suggestive of an infectious process. Indeed, when we reached the area of the fracture, we found infectious material within the disc space. This was removed along with part of the eroded/fracture vertebral bodies and her spine was instrumented into a more normal alignment. We sent cultures of the infectious material and placed some antibiotic powder into the wound before closing.
 

​During the day, Dr. St. Clair saw several new patients in the wards, one of whom was a man with a cervical spine injury in need of stabilization. The practice of carrying objects on one’s head has existed for centuries in Africa and other developing countries. Unfortunately, this patient was carrying a large load of firewood on his head when he tripped, applying a heavy flexion and axial compression force to his neck, which resulted in a fracture/dislocation at C4/C5. He lost function in his arms and legs almost immediately after the injury, and because the event occurred days before he reached us, his prognosis for recovery of limb function was poor, but he was in need of stabilization to prevent and further deformity or injury from occurring.  We took the patient to the operating room after our second case, where we reduced the dislocation and removed some herniated disc material that was compressing his spinal cord at that level.

​… And then there were eight. Dr. Kerner and her plastics crew left for the airport this morning. Leaving us with a bit of a skeleton crew for the final stretch. We were all sad to see them go. 

​One last group shot with Dr. Kerner and her team. Left to right: Sue, Lance, Lorna, Sean, Megan, Dr. Kerner, Dr. St. Clair, Jordan, Bogden, Alvina and Michelle.
 
We started the operative day with a 12-year-old girl, Sheila, with congenital scoliosis. We instrumented her spine from T3-T12 and Dr. St. Clair performed some corrective maneuvers to get her spine into a more normal alignment.
 

​Our third case was an L3 – L5 decompression and fusion in a lady with back and leg pain.
 
 
Several of our patients presented with lower extremity weakness that persisted despite our interventions. We worked with local suppliers to acquire wheelchairs for these patients to assist with mobility, and many have begun to become accustomed to using a wheelchair around the hospital grounds. Michelle and Jordan even enlisted some of the youngsters nearby (who were eager to help) in the wheelchair training process.

​And succeed we will.
 
We’ve all got a case of the Mondays after a long week and a busy – but fun – weekend. We put that all aside, though, to focus on finishing strong in this last week of the mission.
 
Our surgical case du jour is a young man named David with congenital scoliosis. We corrected his deformity as much as was safe, and fused him into his corrected position. Having never witnessed much pediatric scoliosis surgery at my home institution, I must say it is striking to see the degree of correction achievable. To see the shape of a patient’s spine altered so drastically is something to behold. What is most remarkable is that the majority of the correction occurs in the last few minutes of surgery. Hours are spent exposing and placing pedicle screws, and then just before the surgery is over and closing begins, a few rods are bent just so, the spine is moved here and there, and suddenly – and somewhat miraculously - the patient’s spine looks almost normal, when just minutes before it looked a bit of a mess. 

We planned to have several other surgeries today, but they were cancelled for various reasons. Instead, we spent the rest of the day in the penalty box, seeing something like 30 patients and lining up add-on cases for the rest of the week.
 
Sue: “Have you been outside? There must be 30 people out there in line holding x-rays!”
 
Such is the nature of clinic. It pops up sometimes without warning, and when it rains, it often pours. We did our due diligence and made sure everyone was seen. Many of the patients we saw needed anti-inflammatories and physiotherapy rather than surgery, but we did find one or two patients that were added on to the OR schedule later in the week.

​Jordan didn’t have any lollipops handy, so she rummaged through her backpack and found a pack of stickers. She must’ve stuck 7 or more stickers on this little girl’s face and hands.

​After a long week, Dr. St. Clair decided it was time for the team to have some fun. We took a trip out to Queen Elizabeth Conservatory for a safari. Monkeys, baboons, elephants, antelope (known as ‘kobs’ in Uganda) and crocodiles were amongst the many animals seen that day from the (relative) comfort of our group bus
 
We left at 5am and arrived just in time to see the sun rising over the nearby hills.

​This group of baboons sauntered up to our bus as we were entering the road to the park. Some of the team members threw them a few g-nuts, and they decided to let us pass. Gotta pay the troll toll.
 
The road to enter the conservatory had seen a lot of travel over the years and relatively little restoration. The resulting road surface was littered with massive potholes, and riding in a 20-person bus on said road was a bit terrifying at times, as the bus often seemed to tilt to an almost 90-degree angle while swerving to avoid potholes, but our driver (Hassan) managed it like a pro.
 
Dr. St. Clair: “You thought the other roads in Uganda were bad. They have names for some of these potholes.” 
 
We stopped briefly for breakfast, which was a local dish known as a “rolex”. A rolex is nothing more than warm chapatti rolled around a thin omelette, or “rolled eggs” (you get it).  More importantly, there was coffee. Lots of coffee. 

​After lunch, we went on a 2-hour boat tour of the Kazinga channel, a wide body of water connecting lakes George and Edward. There was a nice breeze on the upper deck of the boat, and those that managed not to fall asleep from exhaustion were treated to a guided tour of some of the local wildlife. We made it all the way to the Congo border before turning around and heading back to the bus.

​We made it back to the hotel around 8pm and had a group dinner before heading off to get some sleep in preparation for the last leg of the mission.

​We only have one week left in the Uganda Spine Surgery Mission, and we still have quite a few patients that need surgical intervention. Though it was Saturday, we decided it would be best to spend the day operating. That is what we came to Uganda to do, after all.
 
We began the day with two surgical cases. Firstly, a young lady named Rose. She presented several days ago with lower extremity weakness and a fracture in her lower thoracic spine that was causing spinal cord compression. We initially thought this was from a traumatic event five months prior, but during the surgery we found evidence of infection in her spine, which may have been the cause of her fracture to begin with. 

​Rose’s T12 burst fracture.
 
The second case was very similar: a man with fractures of his T12 and L1 vertebral bodies. The appearance of the fracture on his CT suggested that infection was involved, and when we opened his back and began to access the fracture site, we spotted infectious material for the second time that day. We removed as much of the infection as we could (we had to remove some of the vertebral bodies themselves, as the infection had eroded the bones, making them unsuitable for fusion) and placed an interbody graft into the leftover space. We also placed some antibiotic powder into the area, doing our best to kill any leftover pathogens.

​Our second case for Saturday. 

​The team at work.
 
Dr. Lieberman has an interesting ritual at then end of his cases: he says a little “prayer” to the spine gods, asking that they grace the patient with a good outcome. After operating with Dr. St. Clair over the last two days it has become apparent that he has several rituals of his own. When placing vancomycin powder into a wound, for instance, he will, without fail, exclaim, “Bugs be gooooooone! Be gone! Be gone! Be gone!” This makes me laugh every time, but he insists that it is entirely necessary for the antibiotics to be effective.
 
Between the first and second case, Dr. St. Clair saw a young lady in clinic who had been in yet another boda boda accident (she was walking along the side of the road when a boda boda veered out of his lane and crashed into her). This poor lady had jumped facets at C4/5 resulting in spinal cord compression and quadriplegia. Unfortunately for her, the injury was once again days before we saw her, and thus the hope for recovery of limb function was dismal. Still, she was in pain from her neck injury and in need of stabilization. We reduced the jumped facets from an anterior approach and stabilized her spine at the level of injury with instrumentation.

​While the rest of the group was operating, Michelle and Jordan were busy tending to the rest of our patients on the wards and in the ICU. 

​Michelle delivering a dose of STAT bubbles to this little guy.
 
 
As mentioned in a previous post, Julius (the patient with Pott’s disease of the spine who underwent a big fusion several days ago) has no family or visitors to attend to him, and Michelle has been kind enough to give him a little extra attention. Today, Michelle and Jordan took it upon themselves to give Julius a bath. With some assistance from others in the hospital, they took Julius outside and gave him a good scrubbing, which I am sure he appreciated.

​After another long day, we got together for some Indian food at a local restaurant. We all shared some great food and a little bit of “Mom’s water” (Sherri’s term for vodka, this time procured by Sue and Lorna from the nearby Nakumatt grocery). Everyone was exhausted and ready for a little R&R. Luckily for us, Dr. St. Clair had a special field trip planned for Sunday. 

​Dr. St. Clair and his team arrived in the wee hours of the morning. They barely had time to shower before the bus arrived to take us to the hospital.
 
We started the day with a bang when Lance (our new device rep team member that just arrived this morning) plugged a broken suction device into one of the wall outlets in the OR. A loud explosion/fireball ensued and the power to the OR immediately went out. Lance also had a black hand to show for it. The power was eventually restored and we were off to the races.

​The team was very happy to have Lance on board. The night before his arrival we were without a device rep, and after a long day of surgery, we spent an hour in the “cleaning room” (a.k.a. the “sluce”) washing, repackaging and wrapping all of the surgical instruments for the next day. Brian had been a pro at this, and he never complained a bit, but after taking on the job ourselves for once, we saw how awful it could be. The question on everyone’s mind that night was, “When is Lance going to get here?” We were all very happy to see his face this morning.
 
Our first case was a young man who had been in a boda boda accident (apparently a person in Uganda is injured every 3 minutes by a boda boda). He presented to an outside facility with paraplegia after the accident, but not transferred to our Emergency Room until several days later. His imaging revealed a T4 vertebral body fracture with retropulsion of bone into the spinal cord.

​We decompressed his spinal cord over the area of injury and instrumented his spine into position to restore stability. Sadly, his prognosis for recovery of lower limb function is poor given the time delay between the accident and his presentation to our hospital.
 
Our second case of the day was a young man with chronic back pain and degeneration/malalignment of several vertebral bodies in his lower back. We instrumented his spine into better alignment and restored normal disc height with an interbody graft.
 
That evening, the whole team got together at a restaurant nearby to have a nice dinner and get to know the new team. 

​Our operative case for the day was a young man named Bashir, who had lived almost his entire life with a progressively worsening scoliotic deformity. Over time this led to lower-extremity weakness that left him almost non-functional.
 
Scoliosis surgery is no small operation. Many cases are long, blood loss is anything but trivial, the post-operative pain is nothing to shake a stick at, and some patients develop serious complications. The fact that these patients are willing to go through with such a major operation is a testament to how deeply they are impacted by this disease. I distinctly remember Dr. Lieberman having a conversation with Bashir wherein Dr. Lieberman bluntly asked (through an interpreter):
 
Lieberman: “Do you understand that your leg weakness might get worse after surgery?”
 
Bashir: “Yes.”
 
Lieberman: “Do you understand that you might not survive the surgery?”
 
Bashir: “Yes.”
 
But Bashir did not hesitate to consent. In fact, he seemed rather eager to get on with it. 

​Bashir, our exceptionally motivated young patient with scoliosis and lower extremity weakness severe enough to prevent him from walking. After a ilittle coaxing from Michelle he could at least stand on his feet with the help of a walker, but it was clear that he needed something more done.

​Bashir’s scoliotic curve. The center line is the primary incision, and the left-most area is where the thoracoplasty was performed.
 
We decompressed Bashir’s spinal cord and instrumented him into position over an 8-hour stretch on Thursday, hopefully preventing any future progression of his deformity. We also performed a thoracoplasty, removing several areas of rib prominence, improving the cosmetic appearance of his back.
 

Jordan apparently learned how to set up a mayo as well.
 
We also said goodbye to many team members today, as the majority of Team One (except for Michelle, Stanley and myself) returned home, leaving us with a skeleton team compared to the 15 or so members present on Monday. Dr. Holman is also returning home tomorrow, but Dr. St. Clair’s team will arrive late this evening to provide a fresh energy and a new set of faces to the group.
 
Lesson of the Day (from Dr. Holman): It is entirely acceptable to order two beers at once after a hard day’s work.