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.

Day 4

Today was our first full day at the hospital, although “full” is an understatement. When we opened the clinic at 10am, the open-air waiting room was teeming with patients and their families lining rows of benches or sprawled on mats on the floor 

The team got right to work; Sherry and Rob left to set up our supply room and prepare equipment for surgery the next day. Izzy, Zvi, Danielle and I were joined by the hospital’s own orthopedic surgeon, Dr. Deo. We parked ourselves in a small room with an examining table and brought in the first patient. Over the next ten and a half hours, we screened 67 patients and selected 16 as candidates for surgery pending results from their imaging. It was a long day, and at times a bit trying; after hours of sitting on a bench in a dark, hot, narrow hallway with minimal food and water, patients began pushing their way into the small examining room. They were understandably anxious; many of them had travelled long distances to Mbarara just to be seen by Dr. Lieberman. We explained sympathetically that we were moving as fast as we could, and they would simply have to wait longer. I was astonished by their patience and resilience. Amina, a thin, frail 85-year old woman with chronic back pain from spinal stenosis shuffled slowly into the examining room with a walking stick. The deep wrinkles in her face folded into themselves each time she winced, emphasizing the extent of her pain. For over 5 hours she had waited quietly and without complaint. After his examination, Dr. Lieberman explained to Amina that he could treat her pain through a surgical procedure called a decompression, though the surgery would carry significant risk given her age. This brave elderly woman became our first surgical patient the following morning. 

As the day dragged on we began to appreciate a specific luxury of North American medical care: the process of waiting. To Canadians like myself and Zvi, waiting a month to see a specialist elicits a groan and some exasperated comment about “the drawbacks of universal healthcare.” Waiting over an hour in an air-conditioned waiting room with cushioned seats and a Starbucks in the lobby prompts a similar reaction. Many of these Ugandan patients had lived for over 20 years with back pain. We saw teenagers and 20-somethings with spine deformities that in North America would have been corrected within the first two decades of their lives.  Here, “waiting” is measured in years rather than weeks or months.

For some patients, their long-awaited visit with Dr. Lieberman brought bittersweet news: they were candidates for surgery, but would have to wait even longer. Kenneth, a short 18-year old with a pockmarked face and a big smile, was born with severe scoliosis and has developed restrictive lung disease as a result of his rigid spine. He walks stooped over to the right because his scoliosis forces his left shoulder upwards. Unable to work with his deformity, Kenneth was hoping that an operation would restore his physical mobility and give him "purpose," as he put it. But to treat Kenneth’s condition the spine surgery team would need three weeks in Uganda, and we only have six operating days here. Dr. Lieberman explained to Kenneth that he would have to wait until next year when there is the possibility of a longer mission. 

67 patients later, we were done for the day. On the drive back to the hotel, we reflected on some of the cases from that day, including Bernadette, a 45 year-old woman who injured her back while pulling a goat tethered to her waist. When one team member wondered aloud why anyone would tie themselves to a goat, Rob kindly provided an answer, as well as our quote of the day: “If you haven’t mutton-busted, you haven’t lived.” 

Day 5

A lot was riding on today: our first day in the OR, our chance to test out the facilities and to work alongside new Ugandan colleagues. Today's successes and failures would mold our expectations of what we can accomplish in a week and would give us a sense of the challenges we would face. For that reason, Dr. Lieberman deliberately selected a relatively straightforward procedure for our first operation, a posterior decompression in which portions of bone are removed to allow more space around a nerve root. We arrived at the hospital around 8:30am and went straight to the operating room to find the anesthesiologist, Dr. Emanuel already prepping the patient, Amina.

Sherri and Rob snapped into action and began setting up instrument tables and equipment while Izzy and Zvi scrubbed in. It seemed like we were off to a good start..... until the power shut off. We stood in the window-lit operating room with the patient on the ventilator for about 20 minutes until power returned. For a first hump, that one was pretty small. Dr. Lieberman "strategically applied " the scalpel to skin and began to make his first incision along Amina's lower spine, only to be greeted with a groping hand on his thigh. Realizing that Amina wasn’t sufficiently anesthetized, Emanuel jumped from his chair, gave her a quick injection of anesthetic and whispered an apology. Our second hump was behind us. The rest of the operation went smoothly and two hours later Amina was on her way to the ICU. 

With a lunchtime clinic scheduled in between surgeries, we barely had time to scarf down our energy bars before heading out to the corridor of waiting patients. One by one, the patients approached Izzy and Zvi holding their X-rays and CT scans. We were able to add two patients to our list of surgical candidates, and sent several more for imaging and follow-up.

In the meantime, Sherri began setting up the OR for the next case, 56 year-old Muhamoud. Muhamoud had severe vertebral lysis caused by tuberculosis in his spine. I was particularly excited for this case because Dr. Lieberman was planning to approach the spine anteriorly (from the patient's front), navigating around the peritoneum (the space behind the abdominal organs) to the vertebral column. As Dr. Lieberman went to make his incision, he once again found the patient insufficiently anesthetized. He looked up to find that the anesthesiologist had left the room, leaving his nurse anaesthetist in the pilot's seat. This wasn't the only hiccup we would encounter that afternoon. As Dr. Lieberman pulled back the iliac vein to find the vertebral column, the nurse anaesthetist tumbled from his chair, grabbed at the ventilator tubing and crashed into the operating room table causing the patient to move. It was simply luck that the vein between Dr. Lieberman's forceps did not tear.

That night at dinner, the team discussed some of the lessons of the day. Our first two surgeries in new territory were sobering examples of the importance of thinking on your feet. When things don't go as planned, improvise. Today's challenges also highlighted some of the prerequisites of good teamwork. Teams of longstanding colleagues (like the Texas team) work like well-oiled machines. They anticipate each other's moves, communicate effectively, share expectations and have standard procedures that help things move smoothly. When veteran teams join forces with new colleagues (as the Texas team did with the Ugandan anesthesia team), processes that used to be fluid can suddenly become turbulent. Care must be taken to communicate effectively, lay down expectations and establish roles and responsibilities. Perhaps today’s anesthetic troubles were not from a lack of competence, but rather from miscommunication and incongruent standard practices.

Finally, and on a more personal level, I learned today that surgery is far more multidimensional than I had thought. Spine surgeries don’t necessarily need to be approached from the back, just like heart surgeries aren’t always approached from the anterior chest. Each approach involves different anatomy and with that, different challenges, considerations and risks. The human body is sort of like a labyrinth for the surgeon; sometimes, the best way of reaching a point of interest is not necessarily the most direct route.

All in all, our first surgical day was a great success. As a team, we fell naturally into our own roles and got through our first two surgeries with only a couple nicks along the way. It seemed like we could count on a very productive and rewarding week ahead. 

Day 1
Annnnd we’re off! The 2013 Uganda Spine Surgery Mission officially began on Thursday, August 8 at London Heathrow Airport. This year’s team of six– the smallest team yet– gathered from a smattering of departure cities, including Dallas, Toronto and Tel Aviv. Flying in from Dallas were team lead Dr. Izzy Lieberman, his daughter (and chef extraordinaire) Danielle, and two veteran spine surgery missioners, scrub nurse Sherri LaCivita and medical equipment sales rep Rob Davis. Dr. Zvi Gorlick, a family physician in Toronto, joined the team for the first time, as did I (Jennifer Teichman), a medical student from the University of Toronto.

After a quick caffeine boost at the airport, we dumped our luggage at airport storage and scurried into London for the day. When a two-hour line thwarted our attempt to visit the Sherlock Holmes Museum, we hopped into a cab and found ourselves at Trafalgar Square after a quick drive-by of Buckingham Palace. All six of us clambered up the gigantic lion statues for our first team photo.

We met Ros Eisen, secretary of the Putti Village Assistance Organization for delectably crispy fish and chips at The Seashell, where Zvi insisted on ordering every dish on the menu that happened to be unavailable that day. Re-energized, we made our way to Big Ben, which several of us were surprised to learn referred to the bells rather than the clock tower itself. Dr. Lieberman surprised us with tickets for the London Eye, which proved to be the highlight of the day. We sipped champagne 40-something stories atop London and congratulated ourselves for a day well-spent. Then, it was back to Heathrow for our 9:00pm flight to Entebbe.

Quote of the day: "No time for dresses."- Dr. Lieberman, after Danielle expressed a desire to change out of her yoga pants and into a dress for our day in London. We mean business! 

Day 2

We touched down in a rainy Entebbe around 7:30am, sleepy-eyed yet itching to get started on the mission! Our collective enthusiasm met its first challenge when my laptop was stolen from the airplane. As a newcomer to the mission, I learned my first lesson of the trip: keep your valuables on you at all times, no exceptions. Our first driver, Eric, then appeared not with the 40-seat bus we thought was to be provided by the Mbrara University of Science and Technology (MUST), but with a small pickup truck and a 6-person van. This was my first hint that things don't always go as planned in Uganda. We loaded the truck with our bags, piled ourselves into the van and started the bumpy 60 minute drive into Kampala, the capital and largest city in Uganda. Our first stop was Case Medical Centre, a private hospital that served as a base for the mission in previous years. This year, however, we were only there to pick up the medical equipment they had stored for us from last year.  Danielle and I held down the fort by the luggage-laden truck while the rest of the team retrieved the equipment. Rumour has it that while hoisting a big bag of surgical equipment, Zvi lamented Izzy's choice of profession, and graciously provided us with our first quote of the day: "Why couldn't you have been an ophthalmologist!?"

After a true feat of space-maximization, the equipment was loaded into the truck and sent off to Mbarara to await our arrival the next day. Meanwhile, we headed to our Kampala accommodations, the Speke Hotel, for a much needed shower and change of clothes. With the whole afternoon still ahead of us, we paid a visit to the Galilee Community General Hospital, a Jewish Hospital in Kampala interested in future collaboration with the Uganda Spine Surgery Mission. We toured the facilities, including the new hospital building currently under construction. It was particularly interesting to learn about some of the considerations given to building and maintaining a small hospital on philanthropic support; the constraints of space, funds, resources and expertise were evident throughout our tour of the main hospital and construction site. Nevertheless, the team agreed that the new hospital promised to be a valuable addition to the community. 

The team returned to the hotel to rest before dinner, a good idea since dinner turned out to be a marathon for the stomach and palate. We feasted on delicious Indian cuisine at Khyber Pass, one of two kitchens at the hotel and a favourite of previous incarnations of the Spine Surgery Mission. By the end of the night, several pants buttons were unbuttoned (mine included), and our droopy-eyed procession made its way to bed. 

Quote of the day (#2): "I'm so full, I don't even have room for a tic tac"

Day 3

Move in day! We awoke to a beautiful morning in Kampala, and hit the road after a hearty breakfast at the hotel. First stop: The Nakumatt Oasis, the Zeus of all department stores. There, amongst the impeccably clean and organized isles, one can find everything from toothpaste and vodka to washing machines and power tools. It puts Walmart to shame. After stocking up on what is reportedly the world's best coffee beans, we piled back into the van and continued the five hour trek to Mbarara. Newly paved, the road to Mbarara traverses a landscape of rolling green hills, flat valleys of cultivated land and dirt paths dotted with shacks selling local fruit, meat, fish and potatoes. There was a collective cringe as we passed trailer after trailer of live bulls packed tighter than sardines, their ferocious horns piercing the air above them. Every half hour or so, the serene landscape was broken by the bustle and dirt of a small village with decrepit store fronts ironically painted in advertisements for Coca Cola and Nokia. Within an hour of the ride, our clothes were covered in a thin film of copper-red dirt kicked up by fellow drivers and boda-boda cyclists. 

local artisan crafts. Like school kids watching their first science experiment, Zvi, Rob and I oo-ed and aw-ed at a demonstration of water spinning in opposite directions in funnels placed on either side of the equator. Cooler still, water placed in a funnel centered on the equator didn't spin at all as it drained! Call me a nerd....

We arrived at our hotel in Mbarara, the Lakeview, and were pleased to find large, comfortable rooms. Anxious to start our work, we gathered our medical equipment and drove to the Mbarara Regional Referral Hospital, our base for this year's mission. We were met there by a spectacular surprise: last year, the hospital had opened an entirely new wing including an Intensive Care Unit, Emergency Department and operating theatres. We set to work right away, unloading the equipment from the truck and transporting it to a temporary storage room in the Emergency Department. 

Unloaded and eager to explore, we began a tour of the new building. The Emergency Department is a bustling continuum of corridors and open spaces filled with beds and curtains, each bed occupied by a patient and surrounded by family members. The spill-over of family members sit quietly on benches lining the hallways, many of whom carry infants. It seemed many of these families had not been home for days. Passed the Emergency Department, we found the ICU, a stark contrast to the crowded hallways of the ER. The ICU is a quiet space with each bed contained in a separate glass room. Computer monitors displaying patients' vital signs hang over the beds, much like one would find in any hospital in North America. Already impressed, we then proceeded to the surgical wing. Dr. Lieberman's expression was that of a kid in a candy shop when he first laid eyes on the operating rooms. Big, bright, clean, well-equipped and windowed... we hadn't expected anything close to this! The team's excitement was palpable.    

We left the hospital elated and even more motivated to kick off a great week at Mbarare. After an "edible" dinner at the hotel, we headed to bed for a good sleep before our first big day at the hospital.

Quote of the day:

"It's ok, you can take your skirt off here.. we're all medical professionals"

"The food is.... edible...."