Today was our first full day at the hospital, although “full” is an understatement. When we opened the clinic at 10am, the open-air waiting room was teeming with patients and their families lining rows of benches or sprawled on mats on the floor
For some patients, their long-awaited visit with Dr. Lieberman brought bittersweet news: they were candidates for surgery, but would have to wait even longer. Kenneth, a short 18-year old with a pockmarked face and a big smile, was born with severe scoliosis and has developed restrictive lung disease as a result of his rigid spine. He walks stooped over to the right because his scoliosis forces his left shoulder upwards. Unable to work with his deformity, Kenneth was hoping that an operation would restore his physical mobility and give him "purpose," as he put it. But to treat Kenneth’s condition the spine surgery team would need three weeks in Uganda, and we only have six operating days here. Dr. Lieberman explained to Kenneth that he would have to wait until next year when there is the possibility of a longer mission.
A lot was riding on today: our first day in the OR, our chance to test out the facilities and to work alongside new Ugandan colleagues. Today's successes and failures would mold our expectations of what we can accomplish in a week and would give us a sense of the challenges we would face. For that reason, Dr. Lieberman deliberately selected a relatively straightforward procedure for our first operation, a posterior decompression in which portions of bone are removed to allow more space around a nerve root. We arrived at the hospital around 8:30am and went straight to the operating room to find the anesthesiologist, Dr. Emanuel already prepping the patient, Amina.
In the meantime, Sherri began setting up the OR for the next case, 56 year-old Muhamoud. Muhamoud had severe vertebral lysis caused by tuberculosis in his spine. I was particularly excited for this case because Dr. Lieberman was planning to approach the spine anteriorly (from the patient's front), navigating around the peritoneum (the space behind the abdominal organs) to the vertebral column. As Dr. Lieberman went to make his incision, he once again found the patient insufficiently anesthetized. He looked up to find that the anesthesiologist had left the room, leaving his nurse anaesthetist in the pilot's seat. This wasn't the only hiccup we would encounter that afternoon. As Dr. Lieberman pulled back the iliac vein to find the vertebral column, the nurse anaesthetist tumbled from his chair, grabbed at the ventilator tubing and crashed into the operating room table causing the patient to move. It was simply luck that the vein between Dr. Lieberman's forceps did not tear.
That night at dinner, the team discussed some of the lessons of the day. Our first two surgeries in new territory were sobering examples of the importance of thinking on your feet. When things don't go as planned, improvise. Today's challenges also highlighted some of the prerequisites of good teamwork. Teams of longstanding colleagues (like the Texas team) work like well-oiled machines. They anticipate each other's moves, communicate effectively, share expectations and have standard procedures that help things move smoothly. When veteran teams join forces with new colleagues (as the Texas team did with the Ugandan anesthesia team), processes that used to be fluid can suddenly become turbulent. Care must be taken to communicate effectively, lay down expectations and establish roles and responsibilities. Perhaps today’s anesthetic troubles were not from a lack of competence, but rather from miscommunication and incongruent standard practices.
Finally, and on a more personal level, I learned today that surgery is far more multidimensional than I had thought. Spine surgeries don’t necessarily need to be approached from the back, just like heart surgeries aren’t always approached from the anterior chest. Each approach involves different anatomy and with that, different challenges, considerations and risks. The human body is sort of like a labyrinth for the surgeon; sometimes, the best way of reaching a point of interest is not necessarily the most direct route.
All in all, our first surgical day was a great success. As a team, we fell naturally into our own roles and got through our first two surgeries with only a couple nicks along the way. It seemed like we could count on a very productive and rewarding week ahead.