As a new member to the team I planned to get ready for the mission by reading past blogs and trip reports.  I thought that would prepare me for the experience and what to expect.  To be honest, there is no preparation or way I can truly capture this experience in my epilogue.  As detailed in my team 3 blog entries, I am a resident orthopaedic surgeon.  A large part of my training involves teamwork, that nebulous concept we all recognize, but is impossible to create at whim.  I began this mission contemplating how a group of eight individuals, who had never met, could gather in a sleep and resource-deprived setting and become the team that was necessary to serve our patients.  We were lucky to have a couple of mission veterans with us including Dr. St Clair, who had assumed a new role as team leader.  What I experienced was how a group of committed individuals could overcome innumerable obstacles to help those in greatest need.  The words “we can’t” didn’t exist. Instead, “let’s find a way” became our team mantra. This team dynamic reinforced my deep belief in the power of gratitude.  Our patients and their family’s gratitude were expressed in the whispered thank yous of a rural villager to the full embrace of an orphaned child.  There was a shared gratitude between the Ugandan medical staff and our team for how much we all learned. I was routinely amazed by the profound gratitude of the Ugandan people.  The appreciation they expressed for something as small as a used pair of sneakers to the care they provided for their families made me reflect on how essential gratitude is to shaping our perspective. 

I was fortunate to have been a part of Dr. St Clair’s team. It was educational and inspirational to join someone as they assumed a new leadership role.  In particular, my perspective of the mission was deeply affected when we lost a young woman with an open femur fracture on our third day in Mbarara.  I was emotionally prepared to be part of a team who always “saved the day”. This was a different situation. Observing how Dr. St Clair efficiently moved through the obstacles in an attempt to get her appropriate care was impressive. Afterwards, he demonstrated that it was OK to “feel” the loss.  This helped our team use the experience as a constant reminder to push ourselves and use every moment to make the greatest difference possible.  It is this lesson along with countless others from technical surgical pearls, to life lessons in teamwork, gratitude, and integrity that made Spine Uganda a life-changing experience.

To those who contributed to this mission, I wish to express my deepest thanks.  To those that are new to the Mission, I implore you to make a difference in any way you can.  Africa is too often portrayed as a hopelessly deprived continent that is impossible to change.  Change comes slowly; but I promise that you can see and feel it in Mbarara.  Nelson Mandela said that things always seem impossible until they are done.  Be a part of making that change.  Please consider getting involved in Spine Mission Uganda and be the change you wish to see in the world.  

Our final days in Mbarara flew by, we made it into round again on our patients and were lucky to have Marvin join us for a final review of the plan.  He again expressed his thanks and we made arrangements for me to send some orthopaedic surgical textbooks his way for the Mbarara residents.   We also settled up with the private ward – one of the previous teams patients Ken had had issues maintaining adequate blood oxygenation and we needed him more closely monitored in the private ward. 

Unfortunately, Uganda has a two-tiered healthcare system and requires cash payment for closer monitoring.  We took care of the family’s bill and paused for a couple of final photos of the hospital.  Our jobs done for now, we said our goodbyes to the patients and the staff.  With a final glance back we boarded the bus and headed back to the hotel.  

We spent the rest of the day preparing.  We had our final breakfast the following morning.   We all agreed that though breakfast was pretty decent, none of us felt the need to have potatoes and onions anytime in the near future for breakfast.  We loaded up on the bus for another organ-rattling drive through the Ugandan countryside.   We took time to stop at the equator and shoot a couple of photos on either side of the hemisphere.  Having fulfilled our mandatory equatorial tourist obligations we climbed aboard the bus with souvenirs and a greater appreciation for the Ugandan skill at bargaining.   Our final stop before the airport was the Kyber Pass.  This little gem of an Indian restaurant has come to be famous amongst the spine mission teams with Brian and Sherron singing their praises about the best Indian food either person had ever had.  I entered optimistic but doubtful, I had witnessed the intestinal havoc Ugandan Indian cuisine had reeked on my team members.  

Brian et al could not have been more right, no words can describe how delicious this meal was – who knew that Kampala was the destination spot for delicious Indian food.  It was a great way to conclude the trip and we all left with our bellies full ready for 22 hours of flight time.

We arrived at the airport and submitted ourselves to three separate personal searches by the heavily armed airport security.  We made our way through the rain and arrived in the airport terminal just in time for another power outage – a occurrence that is so regular that I haven’t even mentioned it in previous blog entries as it is a given daily event.  We stopped for a final photo and exchanged hugs and contact info.    

We headed to our separate seats on the plane, tired, well-fed, and deeply grateful for the experience.  Throughout this spine mission odyssey we had experienced so much and I have searched for a good way to summarize it for the blog.  The truth is that there is no way I can encapsulate it all.  I thought I had some idea of what I would see and I now realize you can’t really understand it until you experience it.  The desperate need for medical care cannot be overstated.  We saw tremendous tragedy and people die of injuries that are easily treated in the first world.  We also saw the tremendous beauty and pride of Uganda and it’s people.  These are a people who know what hard work  and gratitude truly are and you can’t help but be affected by it.   So we depart, each of us grateful for the experiences we had and people we met.  We also depart committed to returning and hopefully bringing the ethos of spine mission Uganda to our own everyday lives.        

We had our final breakfast this morning as a whole team and greeted Hasan, our intrepid bus driver, for our ride into Mbarara.  It was foggy this morning having cooled down to the low 60s overnight (weather I would not have associated with Uganda prior to this trip) as we cruised into the Hospital.  The boda boda drivers seemed to have no concept of poor visibility as they often would shut off their engines and lights to coast down hills oblivious to what might be in front of them.  We arrived with a single case this morning – we would be putting on our orthopaedic trauma hats and attempting to adjust an external fixator on the leg of previously treated fracture.  The external fixator is a system of large diameter pins placed on either side of a fracture with metal tubes spanning the fracture connecting to the pins.  The patient this morning needed his fixator adjusted as his fracture was maligned.  Dr. Kip and I (Eric) attempted to accomplish this task but unfortunately the fracture had had 4-5 weeks to heal in this position and though we corrected things slightly he would need an open procedure to reduce the malignment.  

Having given it our best shot we met up with Dr. St Clair and the rest of the team to do group rounds and make sure each patient had a long term plan.  Denise, our ICU scoliosis patient operated on by the previous team, was doing better and we weaned down her ventilator settings with hopes she could come off of it in a few days.  We moved deliberately through rounds, distributing antibiotics straight from the bottle to Gardenisia (our cancer patient earlier this week) for a UTI and reviewing each patient’s plan with the Mbarara staff and physical therapists.  

Our first big case of the week Eziekel looked great and was walking around comfortably.  Mary, our second case was tired but feeling much better.  I paused to give her a finger-knitted necklace my 8 year-old daughter had given me as a good luck charm.  We also handed out Cliff protein bars to many of the children – unfortunately these children don’t seem to get an adequate protein supply which is an essential building block to healing.   They were all excited to try something new and we handed out chewing gum to those that were mildly constipated – again simple bowel meds are in short supply at the hospital and improvisation of treatment was key.  Interestingly, there seemed to universal agreement by the kids that spearmint was by far superior to peppermint.  Our other two patients Shakira and Sarah were resting.  While Sarah was still in quite a bit of post-operative pain and frowning at us, she lit right up when she got her pillow pet and her caregiver expressed his gratitude.

We finished up rounds and discussed all the patients with Marvin and Dr. Deyo (his supervising consultant physician).  With everyone understanding the plan, we made our way back to the hotel for a late lunch and a fairwell to Dr. St Clair.  Dr. St Clair took time to touch base with us each individually to review the week.   We had a last lunch of chicken palaka, a questionable meal at best before 30+ hours of traveling, and we all said goodbye as he headed out.  For the rest of the day we all took time to catch alittle sleep and get ready for our own departure.   We met for a team dinner and marveled at how a group of 8 individuals could come together in a completely foreign environment and accomplish so much.   

Today was our last “big day” with Dr. St Clair and we were all determined to make it a good one.  After another 5 hours of sleep, the team assembled downstairs for breakfast.  To any observer it was plain to see that we were tired but also that we were focused on making today a success.  We headed to the hospital for a 7:30AM start for our first case, Jadrass is a 54 year old man with severe L3-5 stenosis and weakness of his left leg which makes it difficult for him to walk more than across a room.  For this case the tireless Mbarara surgical resident Marvin was nominated to work alone alongside Dr. St Clair and get one-on-one education on the surgical technique.  Marvin was excited to be in this position and Dr. Kip, Austin, Joan, and I (Eric) headed out to round.  We were focused on making progress with all of patients this morning.   In the American healthcare delivery system if you order an antibiotic be given, a blood draw for a lab, or order physical therapy to walk with the patient you can generally count on it happening.  This is not true with the Ugandan system, we learned that unless one of us was there to physically witness or assist in whatever order we requested there was maybe a 50% chance of it getting done.  This problem is often compounded by the patients themselves who will deny receiving a medication that they’ve already taken in hopes that another dose will make the treatment more effective.  As we moved through our morning rounds we recognized as the final mission team that part of our service was to ensure consistent progress towards discharge.    

For some patients such as Eziekel this was as simple as removing his bulb drain, for others such as Denise (who was on a ventilator) this was more difficult.  We took time to demonstrate to the physical therapist how to mobilize each patient and it was incredibly gratifying to see some of patients take their first post-surgical steps with Dr. Kip.  In addition to our medical care, Joan (Team 3’s caring volunteer) gave her time to encourage the children and hand out Pillow Pet stuffed animals which all of the children enthusiastically expressed their gratitude.  Witnessing the joy this brought them reinforced how important and appreciated these simple acts of kindness are in a patient’s recovery regardless of how potentially overwhelming their clinical obstacles.  

We completed rounds and headed to the OR where Dr. St Clair and Marvin had just finished up.  Marvin was rightfully proud of their case and kept repeating just how much he learned from the experience.   Which was a good thing because for the second case we placed him across from me as I instructed him on the surgical technique to expose his side of the patient’s spine.  Our final major scoliosis case was Sarah, another adorable 8 year old orphan who was born with a defect in how her vertebrae were formed.  Sarah had an extra half of a vertebra (hemivertebra) that was shaped kind of like a triangle and a partial autofusion of two other vertebra resulting in a significant deformity.  As I worked with Marvin on the initial exposure of the spine, I reflected on how much I had learned and how fulfilling it was to share that knowledge with Marvin.  The old adage “see one, do one, teach one” was exemplified on this mission as we moved efficiently through the case.  Drs. St Clair and Kip progressed smoothly through the case, removing the hemivertebra while maintaining careful control not to damage the fragile nerves.  The case went wonderfully and Sarah was able move all of her extremities afterwards.  The case lasted until late in evening, as we finished cleaning up Sherron (our tireless nurse/scrub tech) remarked that though she had never had one in her life, tonight she needed to unwind with a Nile lager    

We all couldn’t have agreed more and headed to the bus, exhausted but riding high.  We made our way back to the hotel and sat around enjoying dinner and each others company.  Sadly this was Dr. St Clair’s last night with us and we all went around the table discussing what we learned.  The mission had touched all of us in profoundly indelible ways.  Perhaps one of the most memorable speeches came from Martin who spoke on what a privilege it was to work with the team and remarked on all that he had learned.  He reminded us that the mission not only helped patients but that what the Mbarara physicians and staff had gained would help numerous patients to come.  Dr. St Clair concluded that the privilege was truly ours and we headed to bed feeling accomplished and grateful for having completed our final large case. 

Quote of the day: We are actually done, that’s it… I need a Nile. – Sherron.

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.