Day 5: A Big Day

This years blog has tried to capture the team 4 experience from varying perspectives of Chris (veteran neuromonitoring tech), David (college freshman volunteer), and myself – Eric (returning orthopaedic resident).  Today was to be our busiest day yet.   We had settled in just after midnight and fired it up at 5:30 am to get a good breakfast and get to the ORs as early as possible.  The usual team gathered for our standard eggs/coffee/fruit with a side of Malerone (anti-malarial medication).  I’d be lying if I didn’t see the fatigue from multiple days operating until late in the evening but everyone had their game face on, ready to make today a success.  Today we had 6 operative cases, 2 operating rooms, 1 scrub tech and very little in the way of orthopaedic trauma implants.  We started the day with Dr. Kayanja and I beginning a thoracic decompression and fusion for Jane, a sweet 54-year-old woman with likely infection.  We continue to work and I broke to prepare for a pathologic left hip fracture while Roman (our other orthopaedic resident) scrubbed in.  We had elected to place a sliding hip screw and plate (DHS) for Edward, a pleasant 44-year-old male with a history of prostate cancer.  Back in the good ol’ US of A I would request the sets we need, the scrub tech would pull all the ancillary supplies (gowns, gloves, sutures, etc) and the case would take less than an hour.   This case was to be a lesson in creative problem solving for me.  I found myself pulling apart random unorganized sets of orthopaedic instruments and cobbling together a mix of instruments most of which dated from the Reagan administration.  We also could not place the patient flat on their back (standard positioning) because the operating table could not have xrays shot through it.  Chris, our neuromonitor and go-to-scrub tech joined me and lent his tireless energy and enthusiasm to the case.  So with the patient laying on his side, Dr. Kayanja joined me and began an odessey of a procedure.  The drilling instruments we had were about as sharp as a butter knife and we alternated cleaning the drill and spraying sterile saline across it to cool down.  To complicate matters, the patient had blastic lesions from his prostate cancer to his hip, which made drilling through them equivalent to drilling through cement with a blunt tipped steel pencil.  I was deeply impressed as Dr. Kayanja and I worked through the case at how cool and collected he was.  Dr. Kayanja is a veteran of Uganda orthopaedic training and his skill and improvisational techniques were in full display.  We successfully completed the case after 4 hours, agreed that would be the last DHS we were going to attempt to place, and drank 2 liters of water to rehydrate from the hottest OR case I have ever experienced.




In concert with our efforts, Dr. St Clair and Roman began another spine case for a hard-working 65-year-old man named Elias who required removal of the back portion of the bone of his spinal canal to relieve pressure on his nerves.  This case went well and we continued the rest of the day accomplishing revision of a posterior fusion for a 70-year-old patient Ampaire as well as a above knee amputation for a severe leg infection of a sweet 5 year old girl Anne.  Its hard to capture just how well we all worked this day, if ever there was a doubt as to our ability to function as a team today put it to rest.   We were constantly running into obstacles and frustrations from lack of instruments to temperamental equipment to the lack of personnel.  However, all these obstacles were overcome as everyone took on multiple roles to serve our patients.  Drs. St Clair and Kayanja focused the team and orchestrated this complex dance of seeing additional patients in the waiting room to making sure the patients we did have actually arrived for surgery.  Chris upped his game and helped us trouble shoot as a scrub tech, Sherron became the circulating scrub tech who always had a creative solution to our lack of materials/resources, David became our xray and back up scrub tech, Roman and I dug through old sets of instruments to creatively assemble our implants, and Lance literally ran from room-to-room as the ultimate jack of all trades OR staff member.  We were also blessed to have Stan, the absolutely tireless Mbararra surgical resident whose indomitable positive attitude and attention to detail made this entire day a collaborative success.  By the end of the day we were all running on fumes but riding high knowing what we had accomplished.  We headed back for another 11 pm dinner knowing just how much we had accomplished and grateful to one another, we were all in the zone together and nothing stopped us from achieving our goals.  

Uganda Spine Mission Day 3

Today started off with the similar routine we had been through the past two days.  We awoke still not fully rested, desperately longing for more sleep, feeling the effects of the brutal combination of a 14 hours of hard work, seven hour jet lag, and only about four hours of sleep.  Despite these factors, at seven on the dot, the team was packed up and headed to the hospital, ready to get tackle whatever the day would throw at us.  From the moment we arrived we could tell that things weren’t going to go our way today.  The hospital had completely lost power       from one of Uganda’s frequent power outages, and we spent the first hour stumbling around in the dark, preparing the rooms, praying the power would be restored soon.  Once it did we proceeded with business as usual and started our first cases of the day.  Running two rooms, Eric and Dr. Kayanja operated in the first while Roman worked with the local orthopedist in the room over.  Despite some hiccups in Roman’s case due to a lack of resources, the surgery was successfully completed after 8 grueling hours. 

While it was mostly smooth sailing for our cases, the same couldn’t be said for the rest of the hospital.  At around 3 p.m. the OR floor went from calm and tranquil to filled with the sounds of shouting, equipment being moved, and rapid footsteps.  A gunshot victim was brought in and hurriedly rushed for surgery.  Resident surgeon Stanley and an emergency medicine doctor visiting from Boston rushed into action.  Despite their best efforts the patient flat lined and no pulse could be found.  Refusing to give up, Lance stepped in and gave compressions in a desperate attempt to give the young man another chance at life, and succeeded in restoring a pulse, but at that point too much time had elapsed, and the patient died later in the ICU.  At the exact moment, across from the hall, a successful C-section had just concluded; the sounds of a baby’s first cries were mixed together with the monotone beep of a flat line HR monitor.  In that moment, the entire circle of life commenced right in front of our eyes, the beginning of one life ushered in by the ending of another.  Unfortunately, the 23 year old student was just one of many deaths that occurred today, an even more elevated number than the relatively high mortality rate.  Out of a trio of triplets, only one child was successfully delivered, and in addition 6 patients died in the surgical ward.  Probably the most striking takeaway from this experience was the differences in the grieving process between Ugandans and Americans.  Death has become such a normal part of daily life in Uganda that often times the death of a loved one is accepted without so much as shedding a tear.  The sister of the gunshot victim showed almost no emotion, displaying a detached emotional stance is only natural when one has dealt with the loss of multiple siblings.  This is in direct contrast to Americans, where with our vastly superior healthcare system, death is such a major shock that we often over-grieve for our loved ones, refusing accept a stage in our lives that is inevitable.  After first hand viewing both coping strategies first hand, I’m not sure which method is better than the other.

Day 1&2: We arrive

Team 4, the grand finale of our 10th year of spine mission Uganda assembled members from all over the world.  Most were veterans with a few newbies to keep it interesting.  As one of the resident members of the team, I (Eric Varley) was back for my second trip.  I reviewed last years blog in preparation and reflected that there really is no way to completely prepare for this experience.  As I made my way again to the exotic Detroit Metro Wayne airport, spent quality time waiting through international security, things seemed vaguely familiar – a theme that would resonate throughout this trip.   I boarded my international flight to Amsterdam and luckily found myself 2 seats back from our team leader Dr. Selvon St Clair and sitting next to our other team leader Dr. Mark Kayanja.  We met the most of the rest of the team: Lance (our multi-purpose rep back for his 2nd trip), Chris & Bognan (our versatile neuromonitors), Sharron (our tireless scrub tech) & David (her hardworking son), and Roman (a newbie 3rd year ortho resident to the team).  We all hopped aboard our flight to Entebbe and tried to find sleep on our second leg of a 26+ hour voyage.  We touched down in Entebbe (luckily all of our luggage joined us) and discovered our fearless anesthesiologist Nur was hung up still in London and would be joining us the next day.  Of course our obligatory group arrival pic was snapped and we piled into our new-ish Mbarara University Bus for a 4-hour jaunt to Mbarara.  While the ride was smoother than years past, between the blaring mid-90s American pop music and proximity of oncoming traffic made sleep elusive.   We rolled into the hotel at 4:30 am with just enough time to rinse off and remind ourselves that sleep is over rated. 

            We met team 3 for breakfast at the hotel and after some catching up we headed out to the Hospital for rounds.   Walking into the hospital was truly a surreal experience for me.  You can’t helped but be jarred by the family members sleeping on floors in the waiting room or the odor of the wards, but there was something deeply familiar about it.  These trips are truly life changing and you can’t help but be affected by re-entering into such an environment.  As with last year, we were all impressed by the efforts of the previous teams and our team coalesced around making a worthy finish to this years mission.  During rounds we met our dedicated Physiotherapist member of the team Michelle, a native of Swaziland and a bedrock member of all the previous teams this year.   We finished rounds and headed off to clinic.  Clinic consists of a room about the size of a small American bedroom with no air circulation and patients lined up out the door.   We psyched ourselves up, pounded some water, and got down to it.  The patients we saw represented a huge spectrum from a torn meniscus of the knee to a 9-year-old child with severe spinal deformity.  Some patients with conditions that would cripple most people in first world countries limped in and listened with simply expressed gratitude for our care.  As the day wore on the room temperature and smell progressively worsened.  As I looked around the room at Dr. St Clair, Roman, and David I realized that I wasn’t the only one hanging onto alertness by my fingernails.  Mercifully after a half dozen patients arrived at 5pm, we were done and headed back to the Lakeview Hotel for dinner.  As we sat around the table our enthusiasm and lack of sleep made for a lot of laughs and rapid cohesion into a team.  We were all excited and headed off to sleep ready to conclude this year’s mission.  

We met up with the Team Two to head to the hospital after enjoying a much needed breakfast. We all pilled on the bus headed to the hospital, filled with excitement. When we get to the hospital, team two began explaining what things we needed to expect during our week here in Uganda. Team Two then starts their last case of their trip, while Dr. Holman and his team head to the clinic to start seeing patients. Dr. Shane Birch created a charting program just for the Uganda mission trip. In previous missions, progress notes were done on scratch paper. With this new program we were able to document assessments, upload exam and radiology photos, and then chart postoperatively on surgical patients. It was an amazing new tool for the mission. 

We quickly learned that a lollipop will always produce a smile on our patients faces even during some scary moments. One of our first pediatric patients was a 7 year old boy named Javita. He has kyphotic congenital scoliosis, and was quickly put down as a potential surgical patients after getting orders for new X-rays and CT scans. 

One of our patients was the very nice Reverend Bwambara. This 54 year old man was diagnosed with a intradural tumor that was putting pressure on his spinal cord therefore, creating progressive weakness on his right side of his body. Without the help of Dr. Holman and his team, he could potentially become paralyzed in the future. Even in the United States, these types of procedures are very risky. Dr. Holman would have to preform this surgery without a microscope or his normal equipment. Dr. Holman was up for the challenge and we put him on the schedule for surgery. 

Dr. Holman, Zain and Rebecca looking at films. 

The next patient to steal our hearts was Innocent. This 9 year old boy, was extremely scared of the team, but quickly warmed up after Rebecca gave him three lollipops. Like Javita, Innocent has hyperkyphotic congenital scoliosis. According to his mother, the extreme curvature of his back was only getting worse. After a careful examination of both Innocent and his radiology films, he was placed on the surgical schedule. 

Patients came from all over Uganda to see Dr. Holman and his team. Over 40 patients were seen in clinic. Some patients came for new problems, some were previous surgical patients needing to be seen for their yearly checkup, and some patient just needed a prescription for medication. Everyone was excited with the potential surgery schedule. After an intense clinic day, we make our way back to the hotel, but first needed to stop by the store to pick up some much needed supplies and enough water to last us a couple of days. The store is known as the Nakumut, similar to a Ugandan Walmart.  It has everything from groceries to large appliances.

After the successful shopping experience,we headed back to the hotel for dinner. Zain and Michelle decided to be adventures and order the whole fish platter. It was big enough to feed a small army!  Shortly after dinner, we tucked in for the night knowing we had two surgeries scheduled for our first day in the OR. 

Quote of the day: Dr. Paul Holman quote for the trip " One Mission, Three Samosas, Two Tucker's and NO Cipro!"