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

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 

The team awoke this morning well rested and ready to get to work. After a quick buffet-style breakfast we boarded the bus and set out for the hospital. The streets in Mbarara are lined with speed bumps every quarter mile or so; and when I say street bumps, I mean foot and a half trajectories that launch whoever’s sitting in the back of the bus into midair- Our daily rollercoaster. Let’s hope one of us doesn’t become the next patient needing a spine operation!

Upon our 8a.m. arrival at the hospital, Sister Rose dropped some heart-wrenching news on us. The oxygen supply was depleted and she wasn’t sure when the resupply would occur: Quite an eye-opening experience. Things we’d never consider obstacles faced in the United States can shut down every surgery here for the day in a matter of seconds. “Oh well, what can we do?” was all that was said to us about the situation and it’s the sad truth. We sat down with Ttendo, the anesthesiologist, and he explained that he would personally make the trip to Kampala today to pick the oxygen up (a sigh of relief for us all).

Disappointed that we wouldn’t be able to operate, we had to make the best of the day. Dr. Holman, Dr. Burch, Laura, and myself began our rounds by visiting young Frank, our surgery patient from Tuesday. Two days after surgery and he tells us that he’s already “feeling much better.” With a little support from the team, he was able to get out of bed and walk around- his first trek since surgery. Once he was nestled back in bed, I pulled some fruit snacks out of my backpack and gave them to him: A well-deserved reward for his accomplishment. His face lit up with an ear-to-ear grin and he gave us a thumbs-up as he tried them.

On the other side of the ICU was Denise, yesterday’s surgery patient. She was in some pain, but that’s expected after an eleven-hour, major corrective surgery. With sensation in all of her extremities, we were pleased with her status. Laura, who does our neuro-monitoring during surgery, got hands on and changed out her dressings. It amazes me everyday to see the compassion this entire team radiates!

After tending to other patients in the ward, we left the hospital for some team bonding. Pulling into the resort I noticed a group of local children, varying in age, playing soccer and rugby in an open field. I had an itch to join them and that’s exactly what I did. At first, the boys were very timid, looking away from me when I asked them questions and giggling when I told them I just wanted to talk, but after a few minutes the tension eased and I was bombarded with questions. “What is the USA like?” “Why do you come here?” and so forth. The boys and I switched off asking and answering questions about each other’s lives and cultures. Eventually, we got onto the topic of dvd’s and to my surprise they had seen lots of movies from the states, like the Avengers and Spiderman. I asked them if they had a dvd player and when they told me, “yes”, I ran to the resort and grabbed the movie Paul (it was the only one I thought they would appreciate) that I brought to pass the time on the airplane and a jumbo bag of jerky. They were ecstatic when I told them it was for them to keep and share! Rugby followed and I learned the hard way how athletic these boys are (or how out of shape I am).

A couple of hours passed and it was time for me to leave for dinner. I said my goodbyes and went back to the resort. Those boys changed my life and I hope I impacted them in some way as well. No surgery was performed today, but I feel as if ‘good’ was done. The Spine Machine Team spent countless hours getting to know each other and I got to spend time with a group of incredible children.

Quote of the day:

“Sorry Dr. Holman, we’re going to have to cancel your surgery for today. There’s no oxygen… or power.” –Sister Rose

It was an early 5:30a.m. start for half of the team this morning, Dr. Holman and myself for a quick, yet exhausting p90X workout (indoors, evading the tree-dwelling monkeys and other dangers) and Laura for a three mile run with the courageous marathon crew. A great start to our first day of surgery!

After a quick, filling breakfast, we were off to the hospital. We joined Dr. Lieberman on his rounds once more before his handing off of the baton to team 2. Although we only spent a day and a half with Dr. Lieberman and the rest of Team Sparta, our parallel vision of the mission to provide the most optimal care for the patients allowed our teams to collaborate with ease.

Following the rounds, we made our way to the OR. Today was Frank T’s turn on the table, a chance at a new life. I never expected it to take two attending surgeons forty-five minutes to insert a foley catheter into in a 13-year-old boy (it has clearly been a while). Where are the nurses? Frank had congenital kyphosis (he was born with a spine that caused him to lean forward). In order to correct this deformity, we had to perform a two-level vertebral column resection to allow for room to straighten him upright with supporting rods and screws. The case went as smoothly as one can hope for- the brief power outages that merely tampered with the lighting didn’t phase the Spine Machine Team. We stitched up around 5p.m. with a successful first case completed.

Surgery was followed with my first experience in sterilization. Hands on would be an understatement. With a bucket of cidex bleach, aprons, eye protection, and layers of rubber gloves, Rob and I hand-washed each instrument using toothbrushes (yes, toothbrushes). It wasn’t the easiest task, but a necessary one for the safety of our patients. We wrapped up the cleaning and left the hospital a little after 6:30p.m.

Tired, yet satisfied with our first day of surgery, we stayed at the resort for a scrumptious buffet dinner and it was off to bed.

Quote of the day-

“How many spine surgeons does it take to put in a foley catheter?” –Nadia  

Day 9 and I can't believe it's already our last day of surgery! How time flies! Dr. Lieberman, Lance and I once again begin our day with a 5:15 am run, on our way out bumping into the second team led by Dr. Holman. They have just driven in through the night from Entebbe and will be taking over where we left off. We bump into Sherri and Dr. Owusu on our way back, taking their own morning run around the hotel grounds...

Everyone is in good spirits at breakfast, probably from the afternoon of rest we had yesterday. We assemble and shortly after take off for the hospital, ready to take on our last day of surgery. Dr. Lieberman and the spine team are scheduled for three surgeries, as is team plastics, aka Dr. Kerner. Two local doctors join her, Dr. Situdwa, a resident, and Dr.Kwikiriza, who is on anesthesia. They are working on a young girl, releasing contractures of her hand and wrist. Their second case is a young man with large keloids covering his neck and ear…

Dr. Lieberman's three cases of the day go well, despite Skylar's neuromonitoring equipment getting fried by a power shortage and being out of commission for the rest of the day (luckily this is the last day of surgery, and team 2 brought their own neuromonitoring equipment)

We conclude our last surgical day earlier than our days before, and after team 2 finishes their day clinic, we head over to the Agip motel for some well deserved dinner and another laughter inducing game of 'heads up.'

Tuesday Aug 6:

It's a bittersweet moment as we head into the hospital for our last morning of rounds. Moreen is getting better daily, as she gains more function in her legs. It is looking promising. Sylvia, our first surgery of yesterday is also doing well. Ivan is asleep but doing well after his second surgery to remove the extensive tuberculosis that was destroying his spine. James is doing much better; he is even able to walk himself to the bathroom. With his straighter spine, he indeed seems a bit taller; we even coax a great big smile from him. Kenneth is also recovering well, and seems to have a better hang of his breathing exercises…

With each patient, we say our goodbyes, and I know I will remember their faces for a long time to come. I hope to myself that I get to see them again one day, that they will all be living their lives to the fullest, and that they will be that much happier.

After we do our rounds, we say goodbye to the staff at the hospital, who have been dedicating so much of their time this week to their patients, learning as much as they could from our teams, in an effort to improve their skills to serve their communities better. As much as our teams had been working all week, the local staff had been the first ones to arrive, and many had left only after we had. The anesthesiologist staff, amongst them Drs. Emmanuel, Joseph and Steven, had all been dedicated to serving their patients all week, along with the anesthesia residents George, Andrew and Sadiq, who had been just as helpful in assisting and learning from the only anesthesiologist of our team, Dr. Lubis. Dr. Marvin Mwesigo had been an integral part of team Sparta, bringing his infectious humor and optimism into the O.R, and teaching us a thing or two about resourcefulness.

We say goodbye to Sister Rose, Prof. Bitariho and Jones, who had been major pillars that had helped hold this whole operation together, coordinating and liaising us with all the patients and ensuring that we were all aware of what was going on with the patients’ care. They had indeed been the brains of the operation on the Ugandan side.

We finish packing up at the hospital; with a sigh of relief and a big sense of accomplishment, we officially pass the reigns to team 2, and leave Mbarara Regional Referral Hospital, hopefully having left our mark.

Day 7 and 8: Saturday and Sunday, August 2nd and 3rd: ‘A bumpy weekend’

Today, the day started with rounds to see the patients who had been operated on and were now recovering in the ICU. Little Isaac is doing great, as is Kenneth, though he is in a bit of pain. James is also doing great. He is lying on his side and I greet him with a big smile. 'I'm fine,' he replies, his usual response. We change all their dressings, and after a quick foray into the adult surgical wards to check on the rest of the post-op patients, we head back to the operating theaters.

Today's only surgical patient for Dr. Lieberman’s team is Moreen, 15 years young, with a congenital scoliosis, and who will be undergoing a correction of her deformity. I get to scrub in once again, and I actually get to place a fixation screw into her spine. The screws are integral to holding the spine straight until the fusion consolidates.

We are just finishing with Moreen, putting in her last sutures, when Lance, who was next door comes bolting into our room, 'We need an anesthesiologist. Ours just bolted out of the door.' Dr. Lubis, our anesthesiologist extraordinaire runs after him, sensing the panic in his voice. We are all puzzled as to what is happening and I hope to myself that everything is okay. Tom who is also next door comes in, a second later, also in a panic, asking for the keys to our storage room. He grabs them, then leaves, leaving us even more bewildered. As we are practically done with Moreen, Dr. Owusu hands Dr. Gorlick the needle holder so that he can complete the suturing and rushes next door to see what is happening. We are left bewildered but praying that everything turns out well! A little while later, Dr. Lubis comes back into the room, as calm as ever and we breathe a sigh of relief as we can sense that things are fine. She explains how their spine patient Eric's oxygen saturation (level of oxygen in the blood) had dropped down unexpectedly to the thirties and had set off a panic in the room as they tried to figure out what was going on. They were preparing to deal with the worst when they realize that one of the tubes for his airway had somehow gotten disconnected. The tubes are re-connected, his oxygen saturation levels go back up, and crisis averted. Eric was team Sparta's last surgery of the day and of the entire trip as they leave the next morning.

Next door, Moreen is finished with her surgery but concern sets in when she wakes up, groggy and cannot move her legs. Her symptoms are variable and she is still in a daze with a high level of anaesthetic on board and also injected locally into her back muscles, both of which could be contributing to the symptoms.  Dr. Lieberman decides to wait and watch. We go to home, tired and anxious about Moreen, and praying for her to recover some movement.

Sunday, our rest day but it's still an 8 o clock start and I find myself chanting to myself the whole while to the hospital 'please let her move her feet,' in reference to Moreen, our patient from yesterday. She is the first patient we see when we get to the hospital. She is still not moving her legs, and so Dr. Lieberman mobilizes the operating team and we immediately take her back to the operating room to prepare for surgical exploration.

We all do our rounds, first in the ICU then in the wards, and then team Sparta (Ortho/trauma team) takes off to Entebbe to catch their flights. The rest of us go back into the operating theaters. Dr. Owusu starts his exploratory surgery on Moreen, discovering and draining a hematoma and then checking to see that the screws and instrumentation weren't compressing her spinal cord. Skylar simultaneously runs some neurological monitoring tests on her. A little later, Moreen is done and we wake her up. She is able to slightly rotate her hips this time and has better sensation in her legs, and maybe a tiny hint of movement. We wheel her back into the ICU, hoping that she recovers swiftly.

We finish our morning at the hospital and head back to the hotel for the rest of the day, getting in some rest and relaxation and capping the day off with dinner at the Agip Motel after a few hilarious rounds of 'heads up…'

Prior to breakfast, while still at the hotel, Dr. Lieberman met with his patient from Ethiopia whom he had operated on at the Texas Plano Health hospital in February. While in Texas, he had undergone a multiple stage procedure to correct a deep infection and a pseudo-arthrosis (loose hardware, bone not healing). The patient reported that he was doing exceptionally well and was gratified to be able to have his follow up appointment in the lobby of the Lakeview resort in Mbarara rather than travel all the way back to Texas!

It is an interesting start to our day at the hospital with our first power outage at 10 am. Hopefully no machines are ruined this time, fingers crossed (incidentally, the C-arm fluoroscopy machine is still not working and is unlikely to be repaired over the span of this mission). I remember Dr. Fisk recounting how one of the local residents, Marvin, had exclaimed after our short power outage yesterday- 'this is Africa', then proceeded to describe how he had once performed surgery for hours without electricity. Hopefully we get our power back soon; luckily we have some generators for the theaters.

Two hours later, the electricity comes back on...

Today Dr. Lieberman operated on 11-year-old James. I'd seen James every day of the week, the first time in our spine clinic and around the hospital each day after that. Every time I saw him, I waved at him and said hi. At first he had responded very shyly and quietly, 'I'm fine,' but over the days, his responses would become more and more enthusiastic. As I stood in the operating theater watching Dr. Lieberman and Owusu manipulate and straighten his spine- a breathtaking process that made me think, how do people even begin to think of doing that- I couldn't help but picture James' face and his timid smile, I could vividly recall him walking around the hospital, or kicking around the soccer ball that we had handed him some days before. I couldn't help but think to myself, I really hope I get to see him stand a little taller, I hope I get to see him smile a little bigger! His lengthy operation concluded a success and he is wheeled to the ICU as I hope for his speedy recovery.

Dr. Kerner starts her cases later than the other teams as she is constantly interrupted and delayed by emergency c-section after emergency c-section, but she eventually gets her operating theatre and gets started.

Dr. Lieberman doesn't start his second patient, three-year-old Ivan, till after 6. Ivan was scheduled for surgery much earlier but disappeared only to be found hour’s later; there had been some miscommunication and his mother had mistakenly been sent to pick up Ivan’s blood, and she had taken him with her. Ivan made it back to the OR just in the nick of time before the 6 pm deadline.

Around the same time, Dr. Kerner also starts her last patient, a young girl with massive keloids on her neck...

I'm back in Dr. Lieberman's O.R just after seven and the lights flicker and turn off again but nobody in the operating room is phased. It's our fourth power outage of the day. Dr. Lieberman asks me to scrub into Ivan's surgery and I hurry to the hand-washing station, excited! It's my first time scrubbing into a spine case and I am thrilled! I assist him, Drs. Owusu and Gorlick, and we try to manipulate little Ivan's spine slowly and carefully. I watch as his spine becomes straighter with each screw tightening; we only use as much torque to get correction yet not cut out through his delicate tuberculosis-damaged spine. Four hours later, we close him up and rush him to the ICU for recovery.

We leave the hospital exhausted at 11:15 pm- a record 15 hours- only after Dr. Lieberman takes care of the patients he finds patiently waiting to see him in the hallway.

Our final surgery tally of the day:

Spine team: 2

Ortho team: 5

Plastics team: 2

8 am start at the hospital and we found patients already lined up outside the hospital, awaiting their consults for the day. We got to the OR theaters and the three teams separated, each beginning their prep routines...

We once again ran into unanticipated setbacks throughout the day, but it's day four, and we're all used to it by now. Nothing is a surprise any more- I was quickly driven into town for a little adventure in search for some new extension chords to replace those that we had blown out in the O.R. I got back a little while later, and it was back to business as usual.

Early afternoon, in between cases, Dr. Lieberman and I grabbed some T-shirts and soccer balls to hand out to some of the orphaned children that he has been taking care of for the past couple of years. The kids lined up and we presented them each with the shirts then coaxed them to smile and pose for the camera. I did so with the sparse Luganda I know and am thrilled as I realize that one of the kids speak Swahili, with which I ask him to smile for the camera. He looks at me, surprised and confused that I spoke his language, but then obliges, grinning cheekily into the camera.

A little while later, I was back observing Dr. Kerner as she finished up with her case. Her patient was maybe 4 years old, and Dr. Kerner had just removed some scar tissue from the little boys cheek, releasing the contracture. As they finish suturing the patient, he vomited and we realized that he hadn’t actually been fasted before the surgery, but we were also relieved that he had not yet been extubated so there was minimal risk of aspiration.

A little later, I walked by Skylar, our neuromonitor and c-arm (x-ray machine) operator extraordinaire impatiently talking to the manufacturers of the machine after a power outage causes it to shut down intra-operatively and it refuses to boot back up. The machine was done for the day (and hopefully not for the whole trip) but the teams manage the rest of the day without it.

I switched back and forth between Dr. Lieberman's last case and that next door, where Dr. Fisk was performing the BKA (below the knee amputation) that had been scheduled from their last day. The amputation was as gruesome as it was intriguing and Dr. Fisk took charge as Lance and Marvin assisted.

Watching Dr. Lieberman and Owusu's thoracotomy and anterior release, I marveled at the beauty of the human anatomy as I watched the patient's right lung maximally inflate after being pumped. I also doubled as videographer for both surgeries (this one and the BKA next door) as we record some video to document the surgeries. 

We once again conclude Dr. Lieberman's operating day with another bout of 'Sweet Caroline,' hollering as a local nurse walks into the room and gives us some concerned looks. All in all, we ended the day having done three ortho/trauma cases, three plastics cases, and two spine cases. As we tried to leave for dinner, we found a few more patients in the hallway, who had been waiting all day to see us.

8 o’clock finish time, we headed over for dinner, this time at the Agip Motel where they had run out of all African food (I guess it’s that popular). We were joined by Dr. Kerner’s son Alex and his friend Afan, who also readily joined us in our daily reflection ritual…
 
Quote of the Day:
‘So what are you gonna do without your balls?’ - Dr. Kerner in reference to the ortho/trauma team missing the femoral heads of the hip prostheses

Runner up quote of the day:

‘Your comfort is our total interest’- Dennis, the Vice President of hospital operations as he and dr. Lieberman discuss our transportation schedule. 

It was a slower paced start to the day, only in terms of the volume of patients to be taken care of, but the work was just as significant, having several lengthy surgeries lined up for the day. Dr. Lieberman and Dr. Owusu started with their first patient, Enid, with what would turn out to be a six-hour surgery, to reconstruct her spine destroyed by Tuberculosis.

Dr. Scharschmidt and Dr. Fisk also begin their case, Jovanis, a Hip arthroplasty.

The hours passed by unnoticed, morning quickly turning to afternoon as the various teams handle setback after setback…

Running back to yesterday's consult room to grab some CT requisitions for Dr. Lieberman, I was tracked down by the mother of Denise, a young girl whom we had seen on our walk through the wards and had sent for some x-rays on our first day. She tearfully described how she thought we would be back to the wards to see her daughter, waiting in vain only to find out that we had held our clinic the day before and that she had missed it. I pulled out my notepad and found Denise's name and the notes that I had scribbled down and agreed to talk to Dr. Lieberman on her behalf. A little while later, he looked at her X-Rays and came up with a plan, agreeing to see Denise the next day with tentative surgery scheduled for the next week. I communicated this to Denise’s mother and thanked her for her persistence. She continuously thanked me and reiterated what a great job the team had been doing and how grateful she was for our presence.

I walked back into the OR where Dr. Lieberman and his team were beginning their last case. As I walked back out into the OR hallways to observe the other ongoing cases, I was quickly recruited by Dr. Kerner who was working on Nadine, the same burn victim that she had been working on the first day. I helped her position Nadine as she cleaned and dressed her extensive burns, breaking a sweat in the arduous and lengthy process and taking a lesson in the importance of stamina from one of the local doctors that Dr. Kerner was working with.

After we transport Nadine back into the ICU, I headed back to Dr. Lieberman's operating theater. I was just in time to watch them conclude their last case, an anterior cervical discectomy and fusion while religiously singing in chorus to Neil Diamond’s “Sweet Caroline”.    

Next door, Dr. Scharschmidt's team also finished up their last patient, after diligently handling some unanticipated events with “old school” tactics.

Another crisis was averted quickly after retrieving our driver's lost phone number and we headed back to the hotel, arriving just after 10 pm; a 14-hour workday!

We concluded the day with another late dinner, and a lesson in capitalizing on one's strengths and also importantly learning to recognize one's limitations.

Quote of the day: Scharschmidt to Lieberman: ‘with the reflexes of a cat she caught the code brown,’ describing Dr. Fisk’s efforts to establish a sterile field.

Runner up quote: ‘Sister rose knows how much I love my biscuits and nuts’ – Dr. Lieberman

Day 10

We couldn't believe it was already Saturday. Our last day in the operating room had crept up on us so quickly. We had only one surgery scheduled for today, however if had the potential to be a substantial case.  16 year-old Sheila has spastic cerebral palsy, a neurological disorder caused by injury to the brain in the perinatal period leaving her non-communicative and non-ambulatory. As a result, her body is tightly curled into the fetal position due to the imbalance between her flexor and extensor muscles.  Because of this muscle imbalance, her spine has developed a severe deformity making it near impossible for her mother to provide care and personal hygiene, and rendering her unable to sit up even with a brace or some form of support.  Sheila's mother carries her daughter draped over her arms. The girl is grotesquely undernourished, a clear sign that feeding her is difficult. Finally, Sheila is in constant pain as manifest by her heartbreaking wail. 

While Sheila will never regain the use of her muscles, nor will she ever walk, Dr. Lieberman could still use metal screws and wires to reduce the curve in her spine and to allow her to sit upright. This would tremendously reduce her mother's burden as caregiver. It might also even help with some of Sheila's pain.

Our morning got off to a good start; we were even ahead of schedule... until Zvi jinxed us by commenting on just that. Within five minutes the entire hospital lost power, delaying our start time. Power returned to the operating rooms within half an hour but the rest of the hospital was still in the dark. The head nurse of the surgical ward even borrowed an outlet in our operating room to boil eggs for her lunch.

Sheila's operation took almost 5 hours. As Dr. Lieberman revealed the spinous processes of Sheila's spine (the parts the form the bumps under your skin), he made an unfortunate discovery. Because she is unable to bear weight and likely deficient in vitamin D, Sheila's bone was very soft.  Worse yet, it wasn't clear that her soft bone could withstand the pressure of the metal wires even after she had healed. Past the point of no return, Dr. Lieberman finished the surgery and Sheila was sent to the ICU.

Sheila's case exemplified some of the ethical dilemmas in surgery, and so our lesson of the day revolved around her. Unlike our other cases from this week, Sheila's operation was not expected to provide significant symptomatic relief. When I asked Dr. Lieberman what the goal of surgery was, he explained that sometimes you have to adopt a perspective that includes the suffering of the patient's family. In Sheila's case, her mother was unable to properly care for her in her current state. Perhaps a straighter spine would allow Sheila to prop herself up and eat, thus improving both her and her mother's quality of life.

Having just completed our last surgery, the team packed up the operating room and stored our equipment for pick-up the next day. After rounding on some of our patients, we left the hospital for our final dinner in Mbarara. We were joined by Dr. Joseph, a surgical trainee at the hospital, and by our trusted middle man, Metu, who takes care of all the shipping and receiving for the mission. Back at the hotel later that evening, the team sat with a bottle of wine and some beers and reflected on a very productive and rewarding week. We shuffled off to bed, each one wishing this had not been our last operating day.

Day 11
Move out day. After a leisurely breakfast at the hotel, Izzy, Zvi, Rob and Dani left for the hospital for a final review of the patients. There they met with Dr. Deo and Dr. Joeseph and as a team changed all the dressings, pulled all the catheters, and provided last minute therapy and discharge instructions.  At the hospital, Rob immediately began retrieving our equipment from storage and loading it with Mr. Metu and his team onto the delivery truck. When all packed, the four made their way back to the hotel to meet up with Sherri and Jen. The six of us then loaded our luggage onto the truck and started the nearly eight hour drive back to Entebbe.

Along the way, we stopped at Lake Mboro National Game Reserve. We spent over two hours driving though the park, taking photos of zebras, warthogs, monkeys, and other indigenous wildlife. It was our first and only tourist experience inside Uganda!

We made it to Entebbe eight hours later with numb bottoms and empty stomachs. In our usual fashion, we discussed the lessons of the day over dinner at the hotel.

With the long drive back to Entebbe to reflect on my experience on the Mission, I realized I had witnessed some of the best leadership and team building skills I have seen yet. Dr. Lieberman is as natural a leader as they come, and from watching him and his surgical team over the past week, I recognized the skills that make an effective team leader: expertise that commands respect; teaching methods that drive pupils to want to know more; organizational skills and the ability to coordinate a network of moving parts; setting an example of patience and perseverance in the face of challenges and setbacks; encouraging team members to reflect on their own learning and their roles within the team; and finally, the acuity to select members of team that have their own expert skill sets and personality types that mesh together naturally. That was one of the most valuable and translatable lessons I learned during my two weeks with the Uganda Spine Surgery Mission.

So that's it! Time to sign off. Tomorrow the team flies back to London and then on to our respective home cities. It was a privilege to be part of the 2013 Spine Surgery Mission, and I look forward to hearing about all the successes of the 2014 trip!

Quotes of the day:

"We still have a wottle of bine"

"Six numb bums"