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. 

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.  

We landed safely in the partially demilitarized Entebbe Airport and quickly realized two things: we had no bus for transportation and the rest of team 3 were delayed out of Heathrow Airport.  An hour and half later, having enjoyed spectacular midnight airport parking lot views, the remainder of team 3 arrived and we all celebrated with hugs, handshakes, and the obligatory group picture.  We were lucky to welcome Brian and Joan (our expert Globus volunteers), Chris (our neuromonitor tech), Sharron (our veteran nurse), and Austin (our enthusiastic but weak stomached high school junior volunteer).  Dr. St Clair stumbled upon our bus driver and after testing the weight limit of our mid-70s party bus, we were off to Mbarara (pronounced "Barara" - though we all agreed it sounded much cooler annunciating the "M").  For the next 4 and half hours (departing at 1:30 AM) we all gritted our teeth and surrendered any feelings of rest, safety, or personal comfort for a rousing shock-free drive over Uganda's questionable highway system.  The number of people out at 3 AM and the complete lack of self preservation exercised by the small motorcycles (called boda bodas) was our first reminder of many that we weren't in Kansas anymore. 

We defied traffic accident statistics and arrived at the Lake View Hotel safe and moderately sound at 6 AM just in time to shower and meet up with an energetic team 2.   Drs. Holman and Burch from Team 2 gave us the basic run down and reminded us to avoid the pork and double check how many beers the hotel charges to our rooms.  Teams 2 and 3 reluctantly re-boarded the bus and were off on a short drive to the hospital. 

When we arrived at Mbarara Regional Hospital you can't help but be immediately struck by just how difficult an environment this is to practice medicine.  The staff who welcomed us were warm and immediately saw to stowing our medical gear.  We got a brief tour of the ORs and then off to the wards to round.  We started our rounds in the ICU where we first met Ken, a 21 year old gentlemen with severe congenital scoliosis.  The severity of this young man's deformity was extreme and he had recently undergone stage II of a thoracolumbar spinal fusion with resection of his vertebral column and resection of several of his ribs.  

This is the sort of case that as a resident is rarely if ever seen.   The surgical treatment you are more often to hear about in a "I was there" heroic story told in the resident's locker room back stateside.  The patient seemed to be improving and we were informed that he had needed to be bag mask ventilated after suffering respiratory failure due to a lack of available oxygen - a resource that is so ubiquitously available you don't even think about it in the United States.   The degree of pathology and the truly jaw-dropping efforts of teams 1 and 2 were to be reiterated throughout the course of this first mornings rounds.   As a resident surgeon, there is a difficult- to-describe mix of feeling excited, incredibly empathetic, slightly overwhelmed and ultimately determined in this type of rarely encountered situation.  We were all impressed by the work of teams 1 and 2 and, though it  wasn't said, we were all focused on concluding this year's spine mission on a high note.  This is my memory of the events earlier today and it should be said that we were now operating on 40+ hours with only a few hours of restful mid-travel sleep.  So of course our next move: clinic.  We arrived at what I can only describe as an open-windowed series of dark exam rooms and found ourselves 6-people deep in the "ortho exam room" which is only slightly larger than a crowded broom closet.  Thus began a blur of an afternoon of clinic.  We saw a mix of patients and ended up having a few get imaging and follow-up with us next year.   We had the assistance of the eager residents at Mbarara of whom all of our teams owe a debt of gratitude.  As clinic wound to a close I caught myself, Austin, and Drs. St Clair and Kip nodding off.  After our last patient Dr. St Clair made the astute observation that we had hit the wall and it was time to bail.  As we waited for our ride in the hospital square we had another few impromptu patient consults.  Our ride mercifully arrived and back to the Hotel for some long awaited, much needed....beers!  We each enjoyed a couple of deliciously cold Nile lagers.  A quick siesta and that brings us to this very moment.  We just finished our first dinner at the hotel's Rhino restaurant where we had our first G.I. causality.  Young Austin, our hopeful but ultimately weak-stomached volunteer, fell to a Indian-chicken induced bout of G.I. distress.  Now with a hearty dose of Cipro and Imodium we all are headed to bed to prepare for the OR tomorrow. 

Quote of the Day: "there are two things you will notice immediately: the smell and the dust" - Selvon St Clair; and dear readers, truer words could not be spoken. 

The past two weeks have flown by and our last day of surgery in Mbarara has sadly arrived. By 7:50am we were driving through the Mbarara Regional Hospital gates. To our left, local mothers stood with their babies firmly strapped onto their backs (a common practice here). To our right, hundreds of boba-boda taxi drivers were congregated, hoping for a day full of business.

The highlight of rounds this morning was witnessing Edith, who was operated on last Friday, courageously stand up on her bed after a painful week of recovery. She’ll be able to return home in the next few days. Promise, who was operated on yesterday, is doing well and we hope she’ll be on her feet soon as well. After rounds, we divided up into two surgery teams. Dr. Burch, Nadia, and Laura set up in OR 4 and Dr. Holman, Dr. Marvin, and I in OR 3. Rob had the honor of bouncing back and forth between rooms to manage the instrumentation (a miniscule task for a man of his capability).

Dr. Burch’s crew was operating on Eric, who needed revision of a previous surgery’s instrumentation. In our room, Dr. Holman was performing an anterior cervical discectomy and fusion on the one and only Revered Sam, who had been patiently waiting the past week for the arrival of the mechanism needed to fix the C-arm. His family put forth funds to buy the part needed and for this superlative deed, the C-arm at the Mbarara Regional Hospital will forever be known as the “Reverend Sam.”

Throughout the day, power outages (every half-hour or so), the lack of functioning suction-tips, and the searing OR temperatures were among the many obstacles we faced. However, with these being the ninth and tenth surgeries we’ve performed under these conditions, we simply weren’t fazed. Both groups successfully finished their operations around 4:30pm and worked together to knock out sanitation in a timely fashion.

The Dean of the Medical University and many of the local doctors we’ve worked with in the past two weeks invited us to a 6pm dinner at the Agip hotel, thanking us for the work we’ve accomplished and the commitment of the Spine Surgery Mission to Mbarara. Knowing that a 6pm scheduled dinner in Ugandan time really meant 6:30-7pm, we weren’t concerned that we were running a bit behind schedule. Once there, it was astonishing to hear facts such as in Uganda, a country of over thirty-seven million people, there are only two orthopedic surgeons (one being Dr. Deo who we worked with throughout the trip)! These facts really helped us to understand the potent impact we’ve had in a short two weeks on the people of Mbarara. Dinner concluded at 9pm and the team relaxed at the resort before catching one last night of sleep in Uganda.

Day 12

Dr. St. Clair and the rest of team 3 arrived at the Lakeview Resort early this morning ready to continue the Spine Surgery Mission in Mbarara. Both teams joined forces at the hospital to unload the new supplies that they would surely need to complete the busy week of surgery that lay ahead of them. Rounds were a collaborative effort, allowing team 3 to familiarize with the post-operative patients they would continue to oversee. Kenneth is showing signs of daily improvement, as is Denise. Reverend Sam, one of yesterday’s surgeries, is less anesthetized today and can move is feet. Eric, the other surgery completed yesterday, is doing well this morning and we hope with time, he’ll regain bowel control. We visit with the rest of our patients and introduce them to the new team, ensuring them they’re in good hands. With each heart-breaking goodbye, we are comforted with the thought that our patients have the potential to live much happier lives.

We say our goodbyes to our loving friends that have helped us throughout our two-week stay. To Sister Rose, who has kept things organized and the tearoom stocked with Chipate and Samosas (local scrumptious cuisine). To Dr. Deo and the local resident doctors, who have gone above and beyond to assist in any way possible. And finally, to team 3, who will finish the last leg of the 2014 Uganda Spine Surgery Mission.

Team Spine Machine went back to the resort, loaded up our belongings, and set off on the six-hour trip back to the Entebbe airport. Along the way, we stopped at the equator for a funnel demonstration and some touristy shopping. 

The lengthy bus ride gave me time to reflect on the past two weeks. Two weeks containing some of the fondest memories of my life and friends I will never forget. We fly out of Entebbe at 1am, overwhelmed with a sense of achievement and the hope that we’ve impacted some of the lives here in Mbarara as much as they’ve impacted ours.

Quote of the day:

“I can’t believe I just peed in an African forest.” –Laura

The team was in good spirits this morning, motivated and determined to knock the last two days of surgery out of the park. Being cut short of a full day’s work yesterday due to power outages only fueled our eagerness and lengthened the ‘To do’ list for today. A minor hindrance that wouldn’t throw off the seasoned Spine Machine Team!

We arrived at the hospital at 8am and after restocking my backpack with dressing supplies, Dr. Holman, Dr. Burch, and I started our rounds in the ICU. All was well for our post-operative patients except for Kenneth, whose oxygen tank was completely empty. The nurses told us that the hospital hadn’t received their oxygen delivery today and didn’t know when it would arrive. With Kenneth going into respiratory failure, Dr. Holman sent me back to the operation theatre to find a local resident doctor who could hopefully catalyze the search for oxygen. I found Dr. Emmanuel prepping for surgery, quickly filled him in on the situation, and we both sprinted back to the ICU together. He immediately found a hand resuscitator and began pumping oxygen into Kenneth. Simultaneously, he questioned the nurses on where there could be oxygen in other areas of the hospital, but much to our dismay, the nurse’s response to him was the same. There was no time to wait for the delivery; something had to be done! Dr. Holman and I scurried to Denise’s room and took the oxygen tank from there back to Kenneth’s room (Denise was stable enough to be off of it). We hooked the tank up to Kenneth and thankfully were able to stabilize him. The reality of the limited resources here and how that affects the feasible care becomes more relevant to us everyday.

A busy morning preceded a long day of surgery. Promise, today’s surgical candidate, was diagnosed with severe Congenital Scoliosis- almost a ninety-degree curve in her spine. To put things into perspective, what looked like her scapula was actually her rib cage! I scrubbed in alongside of Dr. Holman, ready to observe and assist Nadia with her scrub-tech duties. While passing instrument after instrument to the surgeons, I watched as they delicately tied off nerves, removed vertebral bodies, inserted rods and screws, and reconfigured Promise’s spine. Incredible.

The seven-hour surgery flew by and I was taught how to staple up afterwards! Promise was wheeled to the ICU to recover and we wrapped things up after a long day.

Dr. Marvin, a local resident, joined us at the hotel after dinner for some drinks. We further learned about each other’s cultures and broke the news to him that he needs to work on his golf game (he boasted about his eighty-five stroke, nine hole round). After an eventful day and night, it was off to bed.

Quote of the day:

“Do you feel that pulsing structure? That’s her aorta.” –Dr. Burch told me as he gave me an anatomy lesson

Rise and spine! Dr. Holman and I began our chilly Monday morning at 5:30am with a mind-focusing (or simply exhausting) P90X yoga routine. A quick team breakfast followed and it was off to the hospital to begin week two. Nadia was offered to sit out for the day and rest after her boda-boda motorcycle beat down yesterday, but being the champ that she is, she didn’t even consider it an option. Talk about a team player!

With two surgeries lined up for the day, we finished rounds rather quickly and got into the OR at 10am, only stopping briefly by the CT room to burn new images (Dr. Holman’s computer had eaten the original CD). Our first case of the day was the trauma patient we met on Friday, Namu, who had a jumped facet (dislocated joint) in his cervical spine. We performed a complication-free anterior cervical discectomy and fusion on him.

During the turnover of the OR for our next case, I walked outside to catch a cool breeze and visit the ward. We hadn’t seen Frank during our morning rounds and I felt the need to check up on him (always a highlight of my day). Earlier during the trip, a nurse mentioned that Frank had seen some boys playing with new soccer balls around the hospital and had asked her where they had gotten them. I knew that the affable first spinal team had given some out and I was relieved to find an extra in the storage room for Frank! He loved it! 

Back in the OR the second case of the day had already begun, along with Dr. Holman’s 80’s Mega Collection playlist (The Doobie Brothers and spine surgery is quite the combination)! Both Dr. Holman and Dr. Burch were meticulously operating on young Naomie with Kyphosis, attempting to decompress the apex of her curved spine and straighten up her forward ‘hunch’. The surgery pushed the teams knowledge and coordination to a new level. Fluctuation in motor-responses and rolling power outages were among the few hiccups we encountered. However, after six hours of surgery, we closed up with confidence.

At 10:15pm, we left the hospital and grabbed an Agip hotel fish kabob to fuel our empty tanks and it was off to bed. Sleep, spine, eat, repeat!

Day 9:

This morning the team spent some time discussing the incredible pathology that we’ve encountered here in Uganda and how this pathology translates into the strenuous surgeries we’re performing. Dr. Burch thoroughly explained the risks associated with these corrective operations, but also pointed out the fact that in many instances, the patients we’ve seen who’ve neglected having surgery have presented with paralysis. With surgery there’s a chance at a normal life. Without surgery early on in a deformities development, the complexity of the procedure needed will escalate and the chance of permanent neurological deficit will upsurge. With these words of wisdom, we finished our breakfast and went to the hospital.

Rounds jump-started our day. Namu, the trauma patient from yesterday, is doing well this morning and already wants to know when he’s free to leave the wards. He’s got at least one recovery day and some discharge instructions ahead of him. Naomie’s feeling weak in her legs after her operation yesterday, but we hope and predict that she’ll gradually regain her strength.

Dr. Deo found us in the ICU and asked if we’d take a look at an ER patient who arrived yesterday. Edson was presenting a loss of motors and sensation in his legs after lifting a heavy load. A quick scan of his x-rays revealed a burst fracture in his lower back… “take him to the OR!” Dr. Burch explained to me that an injury like this needs to be treated immediately to increase the chance of restoration of feeling and movement in the legs.

The surgery, a five level fusion, went smoothly and felt like a walk in the park after all of the rare deformity cases we’ve completed. Our plan was to perform a second surgery in the afternoon, but an extended power outage stopped us from turning over the instruments that we would need. Instead, we made rounds in the ER before heading back to the resort for the night. The team ate dinner, stayed up sharing stories for hours, and went to bed hoping the power would be back up at the hospital in the morning enabling a more productive day.

Quote of the day: “So now you guys are going to start working on that humpdy hump?” –Rob said while pointing at Naomie’s Kyphosis apex.

It was a later start today for the Spine Machine Team after a ‘festive’ evening. Dr. Holman, Dr. Burch, and myself made the trip to the hospital at 10am to make rounds. Along with the patients we’ve operated on, we consulted five ‘rainy Saturday night’ trauma cases including two broken hips, two femur fractures (one protruding), and one tibia/fibula fracture. Dr. Burch explained the significance of the open femur fracture to the local surgeons, and reluctantly they already had him scheduled for surgery early in the week.

We finished up rounds and went back to the resort for our day off (only because the hospital shuts down on Sundays). We had planned to venture to Lake Mburo National Park for a safari, but it was pouring down rain so we decided to evade the open-roofed, mosquito-infested jeeps. Instead, once the rain had halted, we decided to go on team run to explore the Mbarara countryside. We set out in single file line fashion on the dirt sidewalk, Dr. Burch (an ultramarathon runner) taking the lead and us tailing behind as closely as our legs enabled.

As we swiftly passed by markets and family-owned shops I was able to soak up the culture of this country more than ever before. The elated children hollering ‘Mzungu, mzungo!’ to tell their families that foreign people were passing their homes while waving at us sent chills down my back. Looking to my side at the hilly scenery made the first three miles of the run fly by. However, after a cursory first half of the run, things fell apart rapidly.

I was leading the group on the second half of the run, hill after hill, when I heard a scream and squealing of tires. Confused, I turned around and saw Nadia skid five to ten feet on the rough side-road we were traversing. At first, I thought she had tripped and was falling to the ground by mistake, but out of the corner of my eye I saw a Boda-boda (local taxi motorcycle) fly out of control and I immediately put two and two together. A reckless Boda-boda driver had hit Nadia. I frantically sprinted back to where she stood (yes, she was on her feet after being knocked down by a motor vehicle). She was a little shaken up but after a quick inspection, we determined that it was a fracture-free incident. What a miracle!

Cut up and bruised, we told Nadia to wait with Dr. Holman and Laura while Dr. Burch and I sprinted two miles back to the resort for help. The front desk concierge, after some persuading, allowed us to use her car to go and pick up Nadia and the rest of the team. Nadia didn’t break a single bone and continued to heighten the team’s morale throughout the day. She shocked us all by describing the run as “exciting” (bat-woman never gives in). At this point, nothing can stop the Spine Machine…

We got back to the resort, tended to Nadia’s Boda-boda wounds, and un-winded with a casual dinner. A curveball was thrown at us today and we can only hope that Nadia will have a speedy recovery!

Quote of the day: “Let’s run during the day today so the boda-boda drivers can see us!” –Anonymous