With all the surgeries being done under incredulous circumstances the team ventured to the wards to round on the post op patients. Most nurses and caregivers were on strike, so our challenges continued.  The general wards were divided into a male, female, and pediatric section.  When we entered the building, the concrete floors were covered with water with the morning cleaning crew sweeping the water across the surface to make them as clean as possible.  Blankets and food containers from overnight stays of the families lined the room surrounding the patient beds, which were about 18 inches apart.  Families were our biggest allies when rounding on their loved ones.  Whether a father, sister, or cousin, the family members took ownership of their loved ones lying in the hospital beds.  The language barrier was surpassed by Benon, the orthopaedic officer with us.  For the families, he translated post-op instructions, wound care instructions, follow-up plans, and answers to their questions.
Dr. Perry was the first one to mobilize her patients. We changed dressings and gave instructions to families regarding dressing changes, activity and pain management.  Cindy and Pam instructed the patients and families about wound care and gave them clean tegaderm and gauze we had brought. We passed out ibuprofen and Tylenol pre-packed in little baggies we had prepared. Trying to locate our patients was difficult as there were no patient rosters or room numbers. We continued to the ICU to visit a 12-year-old girl who had undergone a 6-hour spine surgery by Dr. Perry.  She stood up with Dr. Perry’s assistance and her posture was more upright and the kyphotic deformity was gone. As expected she was in pain but am sure she could envision a life of normal activity and posture. 

​   With all the surgeries being done under incredulous circumstances the team ventured to the wards to round on the post op patients. Most nurses and caregivers were on strike, so our challenges continued.  The general wards were divided into a male, female, and pediatric section.  When we entered the building, the concrete floors were covered with water with the morning cleaning crew sweeping the water across the surface to make them as clean as possible.  Blankets and food containers from overnight stays of the families lined the room surrounding the patient beds, which were about 18 inches apart.  Families were our biggest allies when rounding on their loved ones.  Whether a father, sister, or cousin, the family members took ownership of their loved ones lying in the hospital beds.  The language barrier was surpassed by Benon, the orthopaedic officer with us.  For the families, he translated post-op instructions, wound care instructions, follow-up plans, and answers to their questions.
Dr. Perry was the first one to mobilize her patients. We changed dressings and gave instructions to families regarding dressing changes, activity and pain management.  Cindy and Pam instructed the patients and families about wound care and gave them clean tegaderm and gauze we had brought. We passed out ibuprofen and Tylenol pre-packed in little baggies we had prepared. Trying to locate our patients was difficult as there were no patient rosters or room numbers. We continued to the ICU to visit a 12-year-old girl who had undergone a 6-hour spine surgery by Dr. Perry.  She stood up with Dr. Perry’s assistance and her posture was more upright and the kyphotic deformity was gone. As expected she was in pain but am sure she could envision a life of normal activity and posture. 

​We rummaged through the fabrics and shoes and jewelry and wandered in and out of the alley ways.  Almost ready to leave, we heard “Doctor, Doctor” coming from the street.  It was one of our patients who had just received an injection yesterday!  What are the chances??  Dr. Kotton stopped and she said she needed a prescription for physical therapy but had forgotten to get it yesterday.  He wrote the words “referral to physical therapy” on his business card and we bid her ado.
We returned to the hotel and a few people went to Lake Mburo to do some sight-seeing, but most stayed at the hotel to rest.  Dr. Perry had a meeting with the Dean of Mbarara University Professor Gertrude Kiwanuka who is a powerhouse leader for the University.  She also met with the International Health officer Sheila Niinye Olivia, and they brainstormed about ideas to build the program and relationship with the spine teams from the USA and Uganda.  Together we can build on an established relationship to make access to medical care continue beyond the week-long spine camps.
The day closed with everyone retiring to bed relatively early (except me writing this blog) in order to rise early at 3:30 AM to depart for our SAFARI!!!!!

​A power outage? Oh no! A medical strike and now a power outage, what more can go wrong, can this be remedied?  How can it be remedied and how quickly?  With five cases scheduled for the OR today we sat silently in a dark room waiting and praying for the power to be restored.  Please let there be light! Our prayers were answered as Dr. Kisitu informed Dr. Perry that the hospital generator was being connected to the operating room. What a relief!!! Did I say what else could go wrong? Well the good news is that we now have power in the OR, but the bad news is that we had no oxygen because the oxygen source was connected to power only.
There were no oxygen tanks for use in the entire hospital.  We all collectively sighed but Dr. Perry had this under control as she paid for oxygen tanks to be delivered from an outside facility. We were back on track or, so we thought.
Okay, so something else went wrong. Scrubbed and ready to go for the first case, which was a cervical decompression Dr. Perry and Dr. Barnard were suddenly informed that the newly purchased oxygen tanks were empty and once again a delay in the OR.  Frustrated the doctors removed their sterile gowns and caps and sat quietly wondering what else could delay this day in the OR and what they would tell their patients that have been waiting so long for their surgery.
Good news, good news! The tanks were not empty after all, they simply need to be unlocked appropriately. Nevertheless, the mishaps of the morning were water under the bridge and it was full speed ahead. Dr. Perry and Dr. Barnard scrubbed in once again and the first case began.

​Can I just say how excited I was when our scrub tech Andrea asked If I would like to be a circulator on the first case, this was my first trip ever into the OR and I was super excited.  YES! YES!! YES!!! My responsibility was limited to retrieving and opening a bottle of saline wash, but it was the most exciting experience ever second to being enthralled by what I was witnessing as Dr. Perry worked on the spine of the patient on the table.
Soothing music permeated the room as the doctors operated with laser focus, it was a tremendous sight to behold and an experience I would never forget.
With no clinic scheduled for the day, the OR was the center of our day and Dr. Ryan Kotton naturally stepped into the OR as second assist to Dr. Barnard on a lumbar case, while Dr. Perry began the third case a 14-year-old girl with a congenital deformity of her spine at L1/2 with an 80-degree kyphotic angulation.   Witnessing the precision and focus required for their craft in unreal and yet so real.  I was also able to see how integral both Andrea our scrub tech and Max our Medtronic rep were to the success of every case.

​Everything was going spectacularly, the lights came on and the generator was no longer needed to power the OR. About two hours later, the doctors were closing on the third case and OMG! The lights went off and the generator was no longer connected to the OR. Luckily the power outage only lasted a few seconds and the case was completed without issue.
Would you be shocked if I said the power went out for a fourth time? Well, it did but luckily Dr. Perry was closing on this patient and the RN Cindy jumped into action with the flashlight from her iphone to illumiante the area needed to finish the case, whew!! That was a close one.
                                                                    
With four power interuptions during surgery and oxygen running low, Dr. Perry decided that it was no longer safe to continue opearting, she  simply could not and would not compromise the safety of her patients and would need to pull the plug on the last case of the day.  Our 5th patient of the day was devasted about the news the her surgery was cancelled but her safety had to be priority number 1 above an elective procedure.
As an end of the day routine, the clinical team rounded to capture our post-op patients from the week despite the absence of a post surgical roster with their location. 
Technically, today was our last day in the OR as the rolling strike continues in Uganda. Without an anesthesiologist we can no longer operate ☹.  We tried to hire a private anesthesiologist and also asked for the chief resident to stay.  He was willing to do so, however, the powers that be of the Mbarara Anesthesia team did not approve that.
After such a challenging day, we all decided to have dinner at Café Havana to unwind, reflect and enjoy each others company.  Our dedication to serve our patients has been our number one priority since we arrived in Mbarara on Saturday and we have used enginuity to resolve setbacks both minor and major.  However, we must know when it is time to pull the plug. Dr. Perry’s lesson of the day was that she very rarely says “no” but she had to say “no” today to prevent catastrophe from happening on her OR table.  We were all extremely proud of her for the leadership she demonstrated and supported her decision 100%. 

​Anger isn’t the word, but disappointment, frustration and disillusionment might be more adequate words in terms of conveying the emotions our team feels today. It seems that a doctor’s strike was scheduled weeks ago, and we were only recently made aware of this information.  Essentially, the country has gone on a doctor’s strike and most health care workers have abandoned post. It’s been quite sad, luckily, we have an awesome team and have been staying until late at night sanitizing our own surgical supplies, buying meds for our patients and enticing doctors to say, unfortunately our efforts have been fruitless.

​Two days into the doctor’s strike coupled with an anticipated anesthesiology strike that would directly affect our ability to operate, the urgency of getting as many cases as possible on the docket is crystal clear.  With a lofty goal of 10 surgeries scheduled today there was no time for morning pleasantries as the physicians headed to the OR at 7am in hopes of helping as many patients as possible, there was no time to spare and it was all hands-on deck. 

​Simultaneously in the clinic setting, Dr. Ryan Kotton had a schedule filled with eager patients needing trigger point injections, corticosteroid injections and botox. However, a mini dilemma presented itself when we lost our translator Benon. With only two Lugandan words in our arsenal, noshasha (pain) and yoroba (relax) panic was about to take over when a very nice medical student walked into clinic in her search for another department.  Luckily for us she spoke English and she offered to assist, disaster averted!
Dr. Kotton was super excited to have this impressionable student in his clinic and he took full advantage of the opportunity to teach her how to evaluate imaging and techniques for administering injections.  What an amazing opportunity for this young student to learn from a world-renowned physician. 

​Have you ever been to a doctor’s office as an adult where you were offered a lollipop prior to getting a procedure done?  Well, you have never seen Dr. Ryan Kotton, his charismatic personality transcended culture in Mbarara as his patients simply fell in love with him. He offered them “special medicine” prior to the procedure and the smiles on the faces of our patients were priceless. In return he received hugs and deepest appreciation for changing their lives in a positive way. Everyone wanted to take a picture with him to show their appreciation, it was an amazing sight to see. If you saw a patient walking around Mbarara hospital with a sucker, you know for sure that they just saw Dr. Ryan Kotton 😊

​This image is one of true focus and determination, one that transcends the constrictions of social and political constraints. This is the focus of our leader demonstrating to her team that if we can think outside of the box, be resourceful, and work together we can accomplish great things for others. Today we finished nine out of the ten scheduled surgical cases, Dr. Perry was a Rockstar!! And again, that is not a biased opinion, simply one based in fact.

​The completion of 9 out of 10 cases was a remarkable accomplishment and the largest amount of surgical case any team has ever done. Fusions, discectomies, laminectomies, decompressions all successful from the surgical standpoint. It was an excruciatingly long day both clinically and surgically and we were not yet finished as all instrumentation needed to be washed, packed and sterilized before leaving the hospital. 
Who needs sleep? Surely not us! As the last case was being completed the team outside of the OR band together to wash instruments, pack them and prepare them for sterilization. As novices to this process we all watched the process intently and Dr. Socci, Pamela, Cindy and myself did what was necessary to make the day a success from beginning to end.
Can you say tired? Never has it been truer that a picture is worth a thousand words!!!!!!!!!!!!!!!!!!!!!!!

​After more than 12 hours of work, Dr. Perry and Dr. Kotton ordered us all dinner, we ate as a team, discussed our day and headed up to bed as we had another long day ahead of us on Wednesday.
***If you are ever in Mbarara Uganda, we strongly recommend Café Havana it’s delicious and a great big thank you to Dr. Tiffany Perry for teaching us that the Waze app works in virtually every country, your genius knows no limit 😊……… Good night, until tomorrow!

​It’s day 3 at the Ministry of Science and Technology in Mbarara, Uganda and we are loving the totality of this journey and all it encompasses. Witnessing the dynamism of the family unit in this country is nothing less than remarkable as families maintain constant vigil for their loved ones and friends accompany each other to appointments not out of obligation but compassion. Despite the systemic challenges faced by local Ugandans in terms of maintaining their own medical records in a notebook or waiting an entire day to be seen by a physician, the spirit of the people remains resilient and hopeful. The opportunity we have been given to be of service is priceless and even though we are here to serve the physical needs of this population, I believe that the people of Uganda have left an indelible imprint on each of us.

​Day 3 began with early morning rotations on the ward as Dr. Perry, Dr. Barnard and Dr. Kisitu evaluated many neurosurgery patients who required their expert diagnostic ability.
The ward overflowed with patients, but each received exemplary care from this team of dedicated and attentive physicians.  Dr. Perry and Dr. Barnard had 6 cases in the OR but let me just say that none of it would have been possible without our amazing scrub tech Andrea Searcy and our extremely resourceful Medtronic rep Max Yue who prepped each OR tray, cleaned and sterilized every instrument after each case. This team came to Mbarara to make a difference in the lives of patients, so with one autoclave machine, minimal outlets in the OR, extremely limited supplies and unimaginable politics these two stellar individuals overcame all obstacles and forged ahead.
Amazing job Andrea and Max, the two of you rock every single day!

​The spotlight shines brightly on our physical therapist Pam who worked in conjunction with the local Mbarara physiotherapy team to assess and provide treatment plans for our post -surgical patients as well as non -surgical patients who would benefit from PT. Quick assessment can turn into treatment that can improve patients’ quality of life. The beauty of physiotherapy is you can make big changes with minimal equipment and a lot of creativity. Working in a room with a chair and a table, Pam was able to address faulty body mechanics and provide basic home programs to allow them to continue to feel relief after they left. Pam’s treatment style is energetic and resourceful, showing the patients that their concerns were of the utmost importance. Most patients left laughing and dancing, which is one of the best medicines. Patients traveled from as far as Tanzania to see the team and one session of therapy can mean the difference between continuing to work to provide for their families or not. For the patients that live closer, they will be able to continue with the wonderful therapists at the hospital in the outpatient program. Pam’s spirited personality was infectious, and the patients simply loved her. 

 While traveling we always anticipate meeting new and interesting people and I would be remised if I did not mention Dr. Adrienne Socci, an assistant professor of Orthopaedics and Rehabilitation at Yale University.  Dr. Socci is currently on a reconnaissance mission at Mbarara hospital in anticipation of assembling her orthopedic team that would return to provide essential support and guidance to the staff here at the Mbarara University of Science and Technology.
                                                      
Dinner and reflection has become customary for our team at the end of the day, and according to Pam, “ Showing people that you care about their own unique circumstances is invaluable in helping them open up to you as a clinician and make positive change in their lives.” This seems to be a universal concept regardless of culture.

​Does anyone embrace the sound of an early morning alarm clock? I think it is safe to say very few, however, our very own Dr. Tiffany Perry began day 2 of our mission with a brisk early morning 4 mile run before meeting the team for breakfast at 6am. As for the rest of us, we hit the snooze button a couple of times, rolled over with pillows over our heads and prayed for an extra hour to sleep. Breakfast was served promptly at 6am as we had many patients anticipating our arrival by 8am.
The anticipation of our first official day at the hospital was palpable, how many patients would we see, what kind of cases would we encounter and how would we effectively communicate with patients who speak only the local language?
We began the day with some starting in the operating room and others starting in a busy clinic in the adjacent building

​The OR began with a T11-L3 posterior fusion for a traumatic L1 burst fracture for patient who was paraplegic.  The second patient was an engineer who had severe lumbar stenosis and underwent a lumbar decompression surgery. 
Hoards of patients lined up to see Pamela for physical therapy and Dr. Kotton for injections.  In between cases and after 2 cases were completed on the Sunday, we all combined forces to see over 100 patients!  Only in Uganda can we see that many in a day!  Examination rooms were filled with patients—sometimes more than one and their families.  The small rooms were humid and warm, and occasional rains intensified the air. With 4 providers seeing patients and our nurse Cindy and administrator Rhondine vigorously typing up summaries of each visit, plans were made for each patient.

​Our last patient walked thru the exam door at 7:15 PM.  We were exhausted, hungry and sweaty.  The evening closed with the traditional buffet dinner at the Lakeview Hotel.  Over dinner, we were able to laugh about the day and share feelings and thoughts about the hurdles we encountered that day.
The words of wisdom of the day came from Max Yue, our Medtronic rep: “Sterilization is a matter of opinion.”  We all took turns around the table after dinner, stating our lesson of the day.  Consensus was we are grateful for what we have, and our outlook when we return to our own practices will be changed forever.  We all retired to our rooms for a good night’s rest to be ready for a big day to follow.

​Our first mission trip to Uganda began at LAX Friday evening November 2nd with an eventful hunt for a missing suitcase, which included essential medical supplies. Tensions were high to say the least, however, after careful scouring of the Tom Bradley International Terminal the missing supplies were found, and we successfully checked six extra-large plastic bins and multiple suitcases that were over capacity, but we were not charged—WHEW!  Breathing a sigh of relief our group of eight, which includes Dr. Tiffany Perry, Dr. Ryan Kotton, Dr. Zachary Barnard a 5th year resident, Andrea Searcy the scrub tech, Max Yue the Medtronic representative, Pamela Mikkelson our physical therapist, Cindy Litman an RN and myself Rhondine Jordan the academic assistant proceeded to our departure gate headed for Istanbul, Turkey.  Twelve hours later we landed in Istanbul followed by seven hours to Kigali Rwanda and finally arrival at Entebbe after a twenty-six-hour excursion.

​While traveling is always an endeavor, coordinating checked luggage, international visas, Ugandan medical licenses, and immunization records for a team of eight adds an additional layer of anxiety to the process. Is everyone prepared with their documents? Will we be held up at customs for any reason?  What will we do if that happens? The questions were extremely nerve-wracking, but our team was absolutely prepared, and the journey went on without a hitch. Upon arrival in Entebbe our driver Isaac stood outside the terminal with a sign that said, “Uganda Spine Camp Team, Dr. Tiffany Perry” and he ushered us into a twenty-eight-passenger bus with our luggage in tow for the four-hour bus ride to Mbarara Uganda.  After making a pit stop at the Ugandan Equator for a bathroom break and snacks our team boarded the bus once again for our destination completely exhausted but totally excited about our mission ahead of us. Exhausted, the team vacillated between periodic naps and absorbing the beauty of the country side in a country we were all experiencing for the first time except for Dr. Tiffany Perry our groups seasoned veteran on her second mission in 2017. 

​You would think that after twenty-four hours of continuous travels and lack of sleep we would embrace our hotel rooms and call it a day until Sunday, however, that assumption would be completely wrong.  Instead, this dedicated team of eight quickly dropped off our luggage and headed directly for the Mbarara hospital to unpack our multiple bins of medical supplies and survey the hospital for surgical evaluation.       

​After swift teamwork the medical supplies were unpacked and organized into groupings and ready for any surgical procedure. Did I say I was proud of our team? And I am not biased, believe me.
 One last endeavor remained before our day would be considered a complete success and that would be clinical rotation.  Our fearless leader Dr. Tiffany Perry alongside Dr. Barnard and Dr. Kisitu evaluated multiple patients experiencing a range of spinal complications, they reviewed available images and decided that two urgent cases would be on tap for Sunday morning OR.

Can I just say that today was an extremely long day but well worth it in the end, two cases will be on the docket tomorrow so stay tuned for the magic!
Our day would not be complete without delicious Indian food, and our group enjoyed every morsel. 
 
Yes, all of that happened on our very first day.  Go Team!!