Uganda Charitable Spine Surgery Mission, August 13-27, 2011
Team: Isador Lieberman, MD, Mark Kayanja, MD, Kris Siemionow, MD, Selvon St Clair, MD, Kirill Ilalov, MD, Krzyzstof Kusza, MD, Zbigniew Szkulmowski, MD, Sherron Wilson, RN, Amy Watson, RN,
Ngozi Akotaobi, PT, Jordan Silverman, medical student, Alex Zapata, equipment technician, IT specialist,
Brian Failla, equipment technician, Globus Medical
Locations: Mulago Hospital, Case Medical Center
Society Sponsors: Health Volunteers Overseas (Orthopaedic Overseas), Scoliosis Research Society, Global Outreach Program
Corporate Sponsors: Globus Medical, Synthes Spine, SpineGuard
Philanthropic Sponsors: MedWish International, AmeriCares, VeAhavta Organization
Local Physicians: Dr. Titus Beyeza (Chief Dept. of Orthopaedics - Mulago), Dr. Norbert Owrotho (Dept of Orthopaedics - Mulago)
This year’s Uganda Charitable Spine Surgery Mission was the most ambitious, productive and involved. The team consisted of a full complement of "international" medical personnel including surgeons, anaesthesiologists, nurses, a physical therapist, medical student, and two technicians. (see Figure 1). Six were veterans of previous missions and the remainder rookies. The veterans were ready to "rock and roll". The rookies had to learn there was more to this than just "hip hop". Despite the generational differences the team was united in their common vision to provide the best possible spine care to the less fortunate of Uganda, to teach those who serve, and to further the relationships for future missions. The team was successful through a focused effort, and a divide and conquer attitude. The highlights of this mission's success, as outlined in the accomplishments list (see Table 1), included performing 18 complex spinal reconstruction surgeries, delivering and distributing over $200,000 worth of medical supplies, and the daily teaching of the local surgical trainees and the physical therapists.
St Clair, Akotaobi, Zapata, Ilalov, seated, Szkulmowski, Kusza, Wilson, Watson
Table 1; Accomplishments 2011
1) 13 participants (including 2 anaesthesiologists and a physical therapist),
two teams, clinics and surgeries at both Mulago and Case hospitals
2) Delivery of over $200,000 worth of medical supplies, divided upon
need to both Mulago and Case Hospitals
3) Distribution of 200 Kinder Kits (school bags) to children
4) 18 complex spinal reconstruction surgeries
5) Daily teaching of residents, scoliosis lecture to staff and orthopaedic residents, physical therapy lecture to therapists
6) Delivery, training and donation of BPAP breathing assistance machines
to Spine ward at Mulago (courtesy of Dr Szkulmowski & Kusza)
7) Formalize collaboration agreement between Case Hospital and
Uganda Spine Mission for future care of the less fortunate
DAY 1 – August 14th:
The mission began at the London Heathrow airport on Saturday August 13th. Jet-lagged from various flights from Toronto, Florida, Texas, and Poland, some remained in the airport while others day-tripped into London before the connecting flight. Once there everyone immediately bonded. Kris, Brian and Sherron were more excited than on past missions. Krzyz & Zbignew (the anaesthesiologists from Poland) were clearly experienced physicians and did not at all seem intimidated. Jordan and Alex on the other hand had no idea what to expect. Kirill in a typical "committed fellows" attitude wanted to know every detail up front. However it was Ngozi who was the local heroin at the first meeting once she broke out the new team shirts. It was a special moment when in the middle of Huxley's ( a pub at Heathrow ), over two tables pushed together, strewn with empty plates and beer glasses, with travelers from around the world looking on in wonderment, that 10 individuals peeled off their existing shirts, with no inhibitions, and transformed into the Uganda Spine Surgery Mission Team by donning the new team colors (Black and Red). Lieberman in a moment of pride wanted to start chanting "mean machine, mean machine" reminiscent of the movie "the Longest Yard".
For others, the mission had already began. Mark Kayanja (Surgeon), the motivation for the first Uganda Spine Mission 5 years ago, arrived on Monday August 8th. He was joined by Amy (RN) and Selvon St. Clair (Surgeon) on Tuesday, after their unanticipated passport problems. Together, they saw over 30 patients in the clinic and performed three surgeries. The surgeries included:
1) a T10-L1 posterior fusion for 20-year old male who fell from a mango tree 6 weeks prior, 2) the removal of an abscess causing kyphosis (hunched posture) in a 9-year old girl suspected of having tuberculosis of the spine, and 3) repair around an irritated nerve in the lower back of a 39-year old woman with back pain and numbness of her leg. They had triaged four more patients for surgery in preparation for the arrival of the others so that the team could immediately initiate operations.
The team landed in Entebbe at 7a.m. local time exhausted from consecutive overnight flights only to learn that the airline had misplaced two bags: of course they belonged to Dr. Lieberman (see figure 2). This year's drive to Kampala was familiar for the vets and eye-opening for the rookies. All snapped shots of the diverse scenery, lush landscapes and busy town markets.
Once at the Golf Course apartments the rookies were pleasantly surprised, with the veterans even more so. For them the homecoming to apartments 353/356 was nostalgic and gratifying. The apartments were in good repair with new mattresses, and best of all no "brown water". Despite the clean look of the water Lieberman still warned everyone to use bottled water for all personal needs.
After settling in the team had their first organizational strategy meeting. Two surgeries had been scheduled at Mulago, Kampala’s general hospital and another two at Case, a private hospital nearby. A clinic was planned for 15 orphaned children who were traveling to Kampala for evaluation. The team discussed the challenges to be overcome, including licensing and new regulations about moving the critical equipment between hospitals. The remainder of the first day was taken up with naps, grocery shopping, dinner at the nearby Serena Hotel, and sharing thoughts and laughs in anticipation of the days to come.
DAY 2 – August 15th:
At 7:30am, two full vans left the central command center (code for the rental apartments) for Mulago and Case Hospitals. The plan for the day was ambitious: 4 surgeries and a session in the penalty box (code for spine clinic).
As the team entered the Mulago government hospital, the veterans recognized the chaos and the rookies dropped their jaws once they all took in the overcrowded, unsanitary, poorly maintained and undersupplied spine ward (see Figure 3) and operating room – a stark contrast to the hospitals they are accustomed to, but a welcome home to the poverty-stricken peoples of Uganda. The team was warmly welcomed back with smiling faces from the nurses, administrators and house staff, following which came the call to action.
After the obligatory meeting with Professor Titus Beyeza (the Head of Orthopedics at Mulago) to work out our equipment challenges, Dr. Lieberman and Jordan (Medical Student & Scribe) went to the clinic where they were joined by Amy and Ngozi. Waiting for Dr. Lieberman, with a smile and a hug, was Stella, a scoliosis patient of years past. As in the past the entrance to the penalty box was stacked with a line of patients coming from all corners of the country, who had travelled days anticipating the spine team's arrival (see Figure 4). That day the team evaluated 19 patients (7 follow-up and the rest new) with a variety of spinal pathologies, each more complicated than the last. Of these patients, 7 would require surgery. Dr. Lieberman began strategizing just how the team would divide and conquer.
Meanwhile in the Mulago O.R., the team performed two successful surgeries, led by the pace setter Mark Kayanja and assisted by the able bodied Kirill Ilalov (Spine Fellow). In the morning, they operated on a broken neck (C3/C4 fracture dislocation) in a 64 year-old man who was paralyzed below his shoulders after a backward fall. He waited for 8 days at home in the hopes of recovery before his family brought him to the hospital. The second surgery was to strategically stabilize the crushed lumbar vertebrae (L2 burst fracture) in a 39 year-old woman with neurological deterioration who’d fallen off a truck four weeks prior.
At Case Hospital, St Clair and Siemionow (with names sounding more like a law firm than the valiant spine surgeons they really are) operated on a 63 year-old lady with age related spinal degeneration causing compression of the nerves to her legs (L3-L5 stenosis); she had trouble walking and standing on her own. The scruffy but always reliable Brian Failla (Equipment Manager), with the assistance of Alex Zapata (the newly designated Spine Mission IT person) and Sherron Wilson (the most resourceful O.R. nurse on the planet), were dispatched as part of the Case surgical team. They were responsible for organizing and distributing the tools for all surgeries on the mission. Unfortunately the second surgery at Case that day had to be cancelled because the patient was unstable, with very low blood counts.
To completely round out the first day’s experience the team witnessed some of the mysticism and cultural diversity in Uganda. Among our challenging cases of scoliosis and T.B., Dr. Lieberman pointed out to the team the pock-marked back of one of the children (see Figure 5). The marks are the evidence of a “village medicine man’s” efforts to rid the body of evil spirits by small incisions and blood-letting. In dramatic contrast, later that afternoon, through the gated window in the clinic office, Lieberman noticed an Israeli flag suspended in the open hatch of a parked vehicle (see Figure 6). Jordan’s deep curiosity overwhelmed him and he approached the driver inquiring about the oddity of the flag. “I love the nation,” he exclaimed. Jordan then frankly asked if he or the family were Jewish. “I am Jewish by assimilation,” he replied.
DAY 3 – August 16th:
The morning began with a trip to the warehouse where tens of thousands of dollars of medical supplies were waiting to be sorted and distributed (see Figure 7). VeAhavta, a humanitarian organization based out of Toronto, organized and delivered a 40-foot container also containing 200 "Kinder Kits", bags of school supplies for the spine patients and children in the village of Putti. Mr Metu's crew (the local shipper) Lieberman and Jordan divided up the supplies: two thirds would go to the state run impoverished Mulago hospital and the rest to the Case Hospital for future use by the team and charitable use by the Case medical staff.
Amy, Jordan and Dr. Lieberman returned to the penalty box to review the x-rays and CT scans of the previous days patients. Each study was as unique and special as the children themselves. There were tremendous deformities but nothing too intimidating for Dr. Lieberman. Dr L then painstakingly described the expectations and implications of major surgery to these young patients overcoming the language and cultural barriers. It was imperative that all parties be in favour of the decision. Ultimately surgery was planned for five of the children. For the rest he prescribed exercise and annual follow-up, hoping the deformities will not progress to the point that precludes any future surgery. Fortunately, everyone left with a wide-eyed grin sporting their new red "Kinder Kits" with notebooks, pens, and pencils for school (see Figure 8).
MedWish, an organization based out of Cleveland, who have been wonderful partners for many years now, also donated vitamins and toothbrushes, which will go a long way towards our patients’ general health.
Kirill, Mark, and anaesthesiologists Krzyz and Zbigniew were kept busy in the O.R at Mulago. Their patient was a 63 year-old educated man who, 6 weeks earlier, summer-saulted forward off of his boda-boda (motorcycle) while riding along the country-side. According to a recent hospital audit boda-boda accidents account for over 70% of the casualties seen in the Mulago emergency department and are the commonest cause of spinal cord injury in Uganda. Two hours after his flip, he was discovered laying paralyzed in the field, by a lady who found him with his head sunken into his chest. On his instruction, she grabbed his ears and lifted his head back into place then called for help. Children, do not try this at home! As if this trauma wasn’t enough, he was picked up placed on the back of another boda-boda and "bobbled" along for 2 hours to the nearest hospital, down the cratered roads, with an unstable neck, already paralyzed. It turned out he had dislocated the joint connecting two vertebrae in his neck (a bilateral jumped facet, in medical terminology) and the lady in the field actually “reduced” it to its original position. There was also a small vertebral fracture above the dislocation and damage to the spinal cord lining (a dural tear). Surgery to stabilize his spine and reduce further damage took seven hours. After the surgery it was clearly evident that he would have trouble breathing. Zbigniew, who has a special interest in mechanical ventilation, brought with him a CPAP machine (continuous positive airway pressure breathing device) and applied it to the patient (think of the mechanism as an air hose continuously inflating a tire at the same rate it is losing air through a puncture). We all have no doubt that Zbigniew's efforts spared this individual further suffering and maybe even saved his life.
At Case, Selvon and Kris operated on F.M, a 22 year-old male finance student. In 2005 he’d had surgery for congenital scoliosis which now required revision due to poorly placed hardware. The surgery took 6 hours, which coincided perfectly with the passion-fruit flavoured “6-hour-power” juice that Kris consumed beforehand. F.M. asked many questions about the prevalence of scoliosis in Uganda. In more developed nations, paediatricians and elementary schools screen for abnormal spine growth annually from a young age. When it does occur, measures are taken to prevent extensive curvature. Unfortunately Uganda’s population seems to have missed out on the epidemiology lecture and the incidence is disproportionately high. Even with screening the burden of spinal deformity in Uganda is substantial.
For dinner the team went to the all-time favourite Khyber Pass Indian Curry House. The discussion over the flavourful curry dishes was dominated by Arne, a free-lance reporter from Norway who was interested in learning more about the Spine and Torah missions.
DAY 4 – August 17th:
Today the team split up to tackle three surgeries. At Case, the A-team (Kris, Selvon and Jordan) started the day with ward-rounds and visiting patients recovering from surgery. They were able to discharge a 39 year-old woman who Mark and Selvon had operated on the week before to relieve spinal cord compression that was causing leg numbness and pain. They had also evaluated a new patient, H.K., a 4 year-old boy with C.P. (cerebral palsy, a condition due to low oxygen at birth) muscle spasms in his limbs and delayed mental and physical development. Coincidentally, the surgical patient at Case, 15 year-old A.W., also had C.P. Fortunately, an international organization sponsored A.W. to have surgery to correct his severely hunched posture (kyphosis). The incision was 14 inches long and the team, under the command of Sherron (the REAL boss of the O.R.) and Nurse Betty (actually an anesthesiologist) brilliantly inserted 14 screws and two titanium rods to straighten out the spine.
While the A-team was busy straightening spines, Ngozi and Amy ran physical therapy (P.T.) sessions for the patients recovering at Case. Ngozi worked for hours, sweat pouring down, in the overheated recovery wards. The complaints of the patients were minimal considering their operations, as Ugandans have a much different perspective on pain. Morphine is used sparingly, if at all, as addiction is overly feared. Ngozi was introduced to the new rehab ward, a tiny cubicle with one small bed and a chair (see Figure 9). At first, Ngozi found herself at odds with the staff physiotherapist, but things turned around when they discovered that our Texan hero had a doctorate in physical therapy. She was quickly "volun-told" to assist in patient teaching and to consult on a particularly difficult case of a middle-aged man with 2 months of constant back and hip pain.
Moving to Mulago, the DOUBLE A-team worked on 2 cases. The first was a 73 year-old male doctor with an infection caused by a previous surgery performed by a local surgeon one year ago. He requested to be operated on by Drs. Lieberman and Kayanja to remove the hardware and clean out the infection. The procedure was a success and the doctor had “no pain” when he awoke – just some mild irritation from the breathing tube. For the second surgery, Kirill, (very slowly) acclimatizing to the Mulago O.R., worked with Robert Kasirye, the 4th year orthopedics resident at Makerere University College of Sciences in Kampala. They operated on a 35 year-old patient who broke her neck carrying a heavy jug of water on her head, causing tetraplegia. The surgery aimed at stabilizing her neck to allow her to maintain her ability to breathe on her own.
After a full day with all pistons firing, the team retired to Mamba Point to sample the famous avocado pizza. Who knew that avocado worked with tuna, chicken, anchovies, pineapple and anything else one might normally put on pizza? After dinner, Dr. Lieberman ventured to the airport to pick up Noemi, his mother, and Judah, arguably the only Texan Jewish geologist in the world, and the securely-encased and very much-anticipated Torah scroll.
DAY 5 – Thursday August 18th:
At Case, things were running like clockwork. The surgical patient was a 50 year-old female agricultural field worker with neck and lower back pain that rendered her unable to work. She also had numbness of fingers and toes. She was disabled by spinal stenosis, or narrowing of the spinal canal where the cord sits in the neck. After rounding on the wards, the dynamic duo (Mark and Selvon) performed a C5-6 Anterior Cervical Discectomy (removal of the disc) and Fusion (locking the bones together) (ACDF) procedure. The team strategically exposed the spine, from the front, and masterfully removed the degenerated disc, a rubbery cushion between vertebrae that normally acts as a shock absorber. In this case, it was bulging out backward and compressing the cord, contributing to her stenosis. The disc was replaced by a solid implant to maintain the space between vertebrae, while screws and a plate were applied to the bones to hold them together until the fusion consolidates. The surgeons completed the procedure earlier than anticipated and proceeded to Mulago hospital to heckle the team, gloating about their efficiency and finesse. Sherron decided to take advantage of her early dismissal and head into town to “get her hair did” (i.e. braided).
On the wards at Case, Amy “the team Florence Nightingale” was administering pain medications where needed, while Ngozi “the team Joseph Pilate” was hard at work. Her patient F.T., who had few complaints the prior day, had a very uncomfortable physio session this day, but was committed to getting up and back to school in September, so he pushed through the pain.
Also pushing through the pain of the penalty box were Lieberman and his corner man Jordan, being “rope a doped” by three more patients. One was a follow-up scoliosis patient that Kris and Dr Lieberman had operated on in 2007. She had matured into a beautiful young lady with a straight and pain-free spine. Her x-rays revealed a solid fusion, intact hardware, and a well-maintained correction with a balanced spine. The other two patients were ambitious young teens with aspirations of becoming computer engineers and businessmen, integral to Uganda’s future and who were not at all shy about sharing their ambitions. They both would eventually need surgery for their scoliosis and TB complications in the next couple of years, but wanted to finish high school first. Dr. Lieberman stayed in the center of the ring long enough to discuss all aspects of their predicament with them while displaying an incredible amount of patience, though he’d call it self-control, so as not to let the patients realize that he was rushing to get to the operating room before Siemionow and Ilalov did something he would regret (kidding of course – these guys are top notch!).
Unbeknownst to Lieberman, outside the ring, the surgical action at Mulago had not yet even begun. The patient still needed pre-operative X-rays and the team was waiting on 3 units of blood for transfusion. While waiting, the Mulago orthopedics residents haunted Kirill, Kris and Jordan with articulate and detailed stories of the talented and deadly snakes found in various regions of Uganda. Later that evening the entire building heard Kirill screaming “Black Mamba” in his Malarone-enhanced dream world.
The surgical patient P.T. was a 14 year-old girl with a spine so twisted that her ribs, over time, had pushed out and lifted her sternum (chest plate), leaving her with humps in both front and back. The multi-step surgery would require stabilization of her spine with hardware from behind, then removal of her sternum and fusion of ribs in the front, all the while maintain her ability to breathe in an already constricted rib cage. The decreased lung volume made this a particularly challenging case for our Polish Anaesthesiology pair responsible for maintaining her vitals (breathing, heart rate, and fluids) throughout the procedure. The first step took Dr. Lieberman, Kris and Kirill six hours, and after review of the patient’s status Lieberman and the anesthesiologist pair decided that further surgery would subject her to unreasonable risk. She would need to recover first, and then be evaluated as to the best timing for the second procedure.
Day 5 was a landmark day for Brian, the equipment manager, who, after riding the pines for hundreds of spine surgeries, got to “scrub in” and assist the scrub nurse “sister Sara”. Giddy and camera-friendly, Brian worked diligently and learned that being a scrub nurse is a LOT harder than it looks (see Figure 10).
As with every good story there is always a silent hero. Some one behind the scenes, who quietly goes about his/her responsibilities, unassuming, barely noticeable and never getting the credit they deserve. Well this story is a little different. Alex Zapata was everywhere, was noticeable, and even more so performed above and beyond all expectations, especially with the team’s videography and IT needs.
After an exciting day the team retired to dinner, saddened by the departure of Mark (back to residency training), Selvon and Amy (to their honeymoon), and after waiting a comfortable two hours to be served, they filled their stomachs with curried delights.
DAYS 6-8 – Friday-Sunday August 18-20:
At the end of the long first week, the three mystical days Friday to Sunday seemed to blend together into one.
On the spinal side of things, the mission team split up so some could stay for the surgery on I.K., a 64 year-young female patient who was postponed earlier in the week pending blood test results. Sometimes, a low Vitamin B12 level can cause the same neurological symptoms as an insult to the spinal cord. So, to justify a surgery, the team furthered the work up to rule out a B12 deficiency (pernicious anemia). Overnight Friday, her blood tests came back and showed her to have a normal B12 level, so Kris and Kirill reassessed the patient on Saturday morning and went ahead with the surgery at Case hospital. It was another straight forward spine procedure even with poor lighting and less than ideal instruments.
Early Friday morning, the second half of the team ( Lieberman, Failla, Silverman, Zapata) joined by Noemi Lieberman, Arne Dornebal and Judah Epstein, ventured upon the final leg of the torah mission to Putti, a small village near Mbale (“Em-ball-ay”). “Ohhhhh Lord,” the team prayed, “please deliver us and the precious sefer Torah to the village of Putti.” The apparently “220 km drive” took four hours on treacherously narrow, pitted roads and dusty boda-boda trails to the foot of Mount Elgon in the town of Mbale. When they arrived they were greeted by the village population, adults and children alike, charging the van with jubilant shrieking reminiscent of the peacock mating call. The torah as promised had arrived at its new home.
The history of the Putti Abayudaya (Ugandan for Children of Israel) started in the late 1800s. An elephant hunter named Semei Kakungulu began studying the bible. Upon further learning, he found his connection to the old testament, the books of Moses. He circumcised himself and his sons, a sign of Abraham’s (the first Jewish man) covenant with God. We don’t know how thrilled his middle-aged followers were about this initiation process at the time, but the incredible strength and devotion of the Abayudaya now speaks of their commitment to the Jewish faith. There are about a thousand Abayudaya in Uganda, but the orthodox ones (170 adults and countless children) live in and around Putti.
Torah in hand, Dr. Lieberman and community leader Rabbi Enosh danced under the chuppah (a ceremonial canopy), on the way to placing the scroll into the Aron Hakodesh (holy arc) next to the original paper Torah replica that so compelled Dr. Lieberman to promise the delivery of the real one (see Figure 11). The entire community gathered in the synagogue for a special mid-afternoon service. Nobody could find the words to express their joy and gratitude, but that didn’t stop them from trying. Dr. Lieberman spoke of the meaning of being Jewish, and Jordan spoke of the VeAhavta organization and the Kinder Kits. The kids then swarmed Jordan like the killer bees buzzing about in the papyrus thatched roof just above us and each got a backpack which they wore proudly (see Figure 12).
On Sunday the team visited the Equator and nearby craft shops, sharing the events of days past and those to come. Disappointed by the closing of the famous French-Fries shop, talked up endlessly by the veterans, the team ordered Nile specials and greasy fries at the next local restaurant and once filled moved on to visit the local neighborhood crocodile farm. There the 68 year-old monster croc Cleopatra recognized Lieberman and Failla, boasting its ancient teeth in their presence.
Returning back to Kampala that evening was the most harrowing experience of most of the team member's lives. They were inescapably involved it the worst traffic jam of their lives. Truly bumper-to-bumper, mirror-to-mirror, with boda-bodas crammed to fill the space in between. Veterans noted that it had never been this bad in previous years, and that the recent increase in car-shipping to Uganda has caused dramatic changes in street congestion in the city. The team was convinced that Uganda has the best and worst drivers in the world.
On arrival to Kampala the team returned to Mamba point for avocado pizzas, said their goodbyes to Kris Siemionow, who by the way just ordered a sealed bottle of water for dinner, in fear of the potential gastro-intestinal consequences of anything else, while on an airline flight.
DAY 9 – Monday August 22nd:
Monday morning started with shock and awe. Throughout the week Szkulmowski and Lieberman, like a Swiss train consistently opened the gym at exactly 5:30 am for their workouts. Occasionally Brian and Kirill would wake early enough to get there as well. This morning however the exercise addicted duo were astonished that the girls, Ngozi and Jordan, sporting their morning faces, succumbed to the peer pressure and came to work out as well. The small gym was packed with team members working off the great food of the week.
Once showered and fed the team started with the clinical day and visited the post-operative patients. P.T., the 14 year-old girl with scoliosis and the elevated chest plate, was recovering well on the breathing machine. The second part of her surgery would have to wait until next summer. She smiled at the sight of her new teddy bear, one of several Sherron brought for the pediatric surgery cases.
I.K., the 64 year-old ACDF patient from Saturday noted improvement in her leg pain, recovered speedily and was discharged from hospital. A.W., the 15 year-old boy with cerebral palsy and kyphosis smiled at first sight of the team, and was doing very well.
Surgery at Case began at 10am. The patient B.A. was a 7 year-old girl with congenital scoliosis who was seen in the penalty box one week earlier. She had a T7-L3 instrumentation and fusion procedure, which involves the installation of screws and rods spanning 9 vertebrae and placement of bone chips to grow into and stabilize the spine. Drs. Lieberman and Ilalov strategically placed the Globus-supplied screws then contoured the titanium rods to match the contours of a healthy skeleton. Both would assert that surgery is just another word for “controlled violence.” This surgery went off without a hitch and at the end Kirill patiently taught Jordan how to throw some stitches.
Having completed the sole case for the day earlier than expected, the team decided to relish in the early finish! The original plan was to drop off the equipment back at the apartment, then take a walk through the slums of Kampala. Key word: “planned.” Kirill, Jordan and Brian just had to make one quick stop at Mulago to pick up some instruments from storage for Tuesday’s surgery at Case hospital. The Mulago spine theater was found locked so Brian called Sister Sarah, who said she would arrive in 30 minutes. Two and a half hours later, after Jordan had finished 3 daily blogs and Kirill had become a Ninja Fruit grand master, Sister Sarah finally showed up to unlock the room. The team once again reminded themselves that they were “on Uganda time.”
The doctor from whom the infected hardware was removed was found to have a serious multi-organism infection, resistant to most available drugs, including the broad-spectrum antibiotics he was already taking. A permanent intravenous line and the appropriate antibiotics were ordered. Luckily, he is a prominent physician in Kampala and has the means, the connections and the know-how to afford and self-administer the treatment.
DAY 10 – Tuesday August 23rd:
Before heading to the Case operating room for surgery the team split up and saw post-surgical patients in the wards at Case and Mulago. At Mulago, Zbigniew, Kris and Jordan visited with three patients, who needed their surgical wound dressings to be changed. Patient J.S., a 35 year-old male was running a high fever since his surgery, while patient P.K. had trouble breathing at night, so required help from the CPAP machine. Meanwhile in the clinic up the hill, Dr. Lieberman presented a lecture on scoliosis to an audience of very interested surgeons and residents. It is critically important on medical missions to make a lasting footprint by empowering the local physicians to improve their standard of care in addition to helping patients directly through surgery and consultation. Even Master PT Professor Ngozi, PhD was asked to teach and present on key concepts in physical therapy – at both Case and Mulago.
The surgical case this day was a 15 year-old boy A.T. who suffered from persistent complications of tuberculosis. He had surgery in 2009 for post-TB complications, but afterward developed a chronic, draining infection. Now, his hardware had become loose and he had multiple levels of bony breakdown (osteolysis) and inadequate healing of bone (pseudoarthrosis), with a substantial left-sided abscess. In May, he underwent a procedure to clean it out (debridement) but it was unsuccessful. The current plan was to repeat the debridement of the incision, abscess, and tract and to remove the loose broken hardware. During the surgery, it was impressive just how much granulomatous (gunky) tissue had been created by immune cells attacking the unresolved infection.
A further three new patients were evaluated this day. The first was E.N., a 2 ½ year old girl with congenital scoliosis. She was prepared for surgery on the team's return next year. C.A. was a 24 year-old female with history of progressive leg weakness over three years and lower back pain. She had extreme lower extremity weakness (1/5 on the power scale) and allodynia, the sensation of pain in response to a non-painful stimulus (e.g. gentle rubbing feels like burning). In the absence of imaging studies, Jordan and Kirill exercised their differential diagnosis skills, ruling out vascular and autoimmune causes (the latter not at all common in Uganda) and suspecting a compressive lesion within her spinal cord, like a tumor. However, when Dr. Lieberman examined her he concurred that her symptoms are most consistent with a compressive lesion. It was then that she pulled out the secret X-rays of her back and it was clear that she had a focal kyphosis at the T11/12 disc level with a spondylolisthesis and disc resorption. Unfortunately, since the process had been going on for some time, the team felt that the damage was irreversible and surgery would be of minimal benefit. This was sad news to break, but having dealt with immobility for almost three years, it was not surprising to her. The third patient was J.K., a 48 year-old male who was transferred from the trauma unit after a motor vehicle accident. Aside from being paralyzed from the shoulders down, he suffered a head injury and was confused and unable to speak (aphasic). He also had chronic chemical burns over his body, but the team could not illicit the history because of his head injury. His CT scan showed complete obliteration of the spinal canal (bone severed cervical spinal cord).
After a busy and interesting surgical challenge, Kirill didn’t have the stomach for dinner at the beautiful and sometimes delicious Serena hotel. Actually, he didn’t have the stomach for anything but a loading dose of Cipro (antibiotic). At dinner, the team howled at stories of spine missions passed (and present) and after the “Sister Sarah fiasco” the day before, the team did a “what time would Wednesday’s surgery begin” pool, Price is Right style: closest guess without going over wins!
DAY 11 – Wednesday August 24th:
The day began as all the prior days: Lieberman and Zbigniew at the gym, Krzyz lighting up beneath the sunrise, the bearded Brian (now a mountain man) carrying instruments to the car, Ngozi and Sherron chatting away about lord knows what, Alex writing in his journal, Kirill contemplating antibiotics, and Jordan shoveling in his watery oatmeal from a cup. The team was prepping for a big surgery today at Mulago.
Things on the ward were quiet – a good sign considering the upcoming surgical case. While waiting for the patient, Lieberman and Sister Sarah started digging through the storage closet for the Syn Frame retractor system (see Figure 14). It was astounding to see how much could be squirreled away. Lieberman recognized new and unused equipment he brought over, three and four years prior. He and sister Sarah intensely debated the merits of using the equipment versus storing it away, never to be used. The sentiment at Mulago is that the new equipment must be saved. For what purpose though is as elusive as the meaning of life itself.
A further two new patients showed up this day un-announced but certainly welcome for evaluations. The first was E.K., a 45 year-old man with a 3-year history of left hip, leg and thigh pain on walking. Jordan conducted a neuromuscular exam of the lower extremities, which was positive for mild pain on hip flexion and rotation, but no other significant neurological signs. The patient had a physical therapy session with Ngozi, who taught him some exercises to strengthening his back muscles.
The second patient was M.N., a bright 3 ½ year-old girl with a left-sided curvature of her back (a kyphosis and scoliosis) and several other health issues. She was born with clubbed feet at birth, and had heart surgery at 6 months to repair a hole in her heart which compromised its ability to pump oxygenated blood (a ventricular septal defect). She also had bulging, wide-set eyes and recurrent attacks of pneumonia every two months for which antibiotics were not effective. Along with her syndromic appearance she had a sacral dimple, suggestive of spinal pathology. Despite her physical appearance she was extremely smart and even understood and spoke English. We sent her for X-rays of her spine which verified a congenital kyphosis that will need intervention at some point soon.
Back to the operating room, the first incision was made at 10:24am. The winner of the “what time would surgery begin pool” was Dr. Lieberman. This surgery was on A.T., a 20 year-old man who fell 70 feet into an empty toilet well under a construction site then waited 4 days until he was discovered. He had crushed the front of his L1 vertebra and everything above tilted 35 degrees forward. Lieberman and Ilalov started the operation with a prayer, “Ohhhhh Lord. Please allow us the skill and wisdom to complete the operation from the front to avoid further surgery from behind.” A posterior procedure following an anterior procedure would significantly increase the risk of complications for this already debilitated patient. As it turns out their prayers to the spinal surgery gods were answered, as they completed the entire procedure from the lateral (left-sided) approach. They strategically removed 2 broken, floating ribs (11th & 12th), exposed the spinal column, removed the crushed bone fragments, replaced the empty space with a cage (a metal framework with new immature bone inside), straightened the spine, stabilized it with screws and rods from T11-L2, then implanted the native bone from the rib to encourage fusion. Surgery took a total of 6 hours, including a welcome disruption by Dr. Birabwa, the Deputy Director of Mulago Hospital, who thanked the team for bringing their skills and advanced surgical equipment.
Later that evening the team joined Dr. Titus Beyeza, the Head of Orthopedics at Mulago, to a night of African Dinner and Theater full of native dishes, cultural instruments, elaborate costumes and exotic dances. At the end we all joined the conga line, and Zbigniew showed off his dance moves – his hips don’t lie.
DAY 12 – Thursday August 25th:
The team universally felt that the second week flew by and the final day had come as a surprise. Ngozi had been invited to give a lecture for the Physiotherapists in the New Mulago hospital, where some of our more difficult ICU patients had passed through. Compared to the spinal ward, the New Mulago was the Bellagio. It had been established in the 1960's, as a military hospital and it was considered among the most prominent hospitals in East Africa. In reality however, the Mulago hospital, like the spinal ward, is now in serious need of “rehabilitation.” The Mulago PT staff really appreciated Ngozi’s didactic teaching and demonstrations and insisted on exchanging contact information for future correspondence. Ngozi was relieved and delighted that she had gone from "rejected to respected" in terms of the value of her services and relationships with local physiotherapists on the spine mission and her patients. She even got a wave out of B.A., the 7 year-old girl from Monday who wouldn’t crack a smile.
Having already completed 17 surgeries, the team expected a smooth final day in Kampala. But, as you may have guessed, fate struck yet again and the Mulago system tried to siphon off the last bit of team energy. On arrival in preparation for the final case the team learned that the water supply to the autoclave had been disrupted, so the surgical tools could not be sterilized. After a three hour wait, lot's of negotiating, and a stroke of luck that water was flowing again. Skin incision was made at 12:05pm.
The procedure was for M.W., a 51 year-old female school teacher with mechanical back pain with radiation to her legs since an accident in 2001. Two years ago she underwent a decompression procedure but had no substantial pain relief. She wore a back brace and used a cane with only minor relief of symptoms. Recently she had been experiencing right arm weakness and right-sided neck discomfort presumably due to neck problems. An MRI showed degenerative changes and narrowing of the spinal canal and intervertebral foramina (the opening where the nerves exit the spine). The team, with the help of interested local orthopedics residents and students, performed a posterior L4-5 lumbar decompression and fusion. They approached from the back, removed part of the lamina (back wall of the vertebrae) and the arthritic facet joints, gently moved the nerves aside (this low, called the cauda equina, or horses tail) while working to remove the disc and replace it with bone graft and a cage. They also inserted screws to maintain the spinal column stability until the bone fusion consolidated. Despite the late start the team still completed the case efficiently and all went well.
At the end of these two anxiety provoking, yet gratifying weeks, the team was ready to return home, but all struggled with the thought of leaving behind so many in need. Despite the emotions , they left to pack their equipment and get ready for the trip home. On the way out patients expressed their deepest gratitude and pleaded for contact information so they could keep Lieberman and Kayanja informed of their progress.
The team still however had one final challenge, get the equipment packed and collected from two hospitals and loaded onto Mr. Metu's truck (the local shipper) to be sent home, all in time for a celebratory dinner . Brian worked effortlessly to catalogue and box the gear, all the while the others shuttled boxes up and down stairs to the shipping van. Lieberman set a challenge, "dinner at the Lawns by 8pm." The team arrived at 7:55, for a fine meal of Ostrich burgers and Chili Crocodile, serenaded by the clapping of rain on the wooden roof. Over dinner they shared their thoughts, feelings and perspectives on the value of the mission and how things could continue to improve future missions. They spoke frankly of the strength and brother(& sister)-hood of the human spirit, their impact on the community, and how the Ugandan health professionals continue to learn from them and the team learn from the Ugandans.
Epilogues
Isador Lieberman
This year's mission set the standard for productivity, emotions and future goals. New lessons were learned and old lessons were re-affirmed. The veterans were solid and the rookies were dependable.
I am consistently reminded of how many good people there are on this planet. Likewise I am constantly reminded of just how much need there is throughout the world. I strongly suggest that if anyone reading this message has even the slightest inclination to become involved or contribute to such a mission, please seriously consider the opportunity and take the leap to participate. It will change your mindset and your life.
Personally I will remember this mission as the most special on three accounts. I had the privilege of having my mother (Noemi Lieberman) accompany the team and myself on part of this mission; I was accompanied by three of my most respected colleagues (Kayanja, Siemionow & St Clair); and I was able, with the help of many, fulfill my promise to deliver a sefer Torah to the isolated Jewish congregation in the village of Putti.
By virtue of my position I tend to undeservedly get the all the credit for these missions. It is impossible for me to ever fully acknowledge all those who have contributed to the success of this mission. Please rest assured that I will never take for granted all those who have contributed along the way.
Mark Kayanja
Another time, same place, same goal. I looked forward to this mission hoping to continue to make a difference in some patients lives. Running the clinic and operating once again demonstrated the great need in Uganda for spine surgery. We faced difficult circumstances trying to get patients operated upon in Mulago Hospital that ranged from equipment, facilities to personnel. As such we made the best of the situation but we were not able to get everyone who we felt needed surgery onto the operating list in a timely fashion. I found it heartbreaking to have to inform patients with immediate needs that they would have to wait. Even though I worked in Uganda before and had been on previous mission trips, I learnt that you need a contingency plan with several backups. It was refreshing to defervesce through working at Case Hospital where we were able to complete the cases we had scheduled in a more timely manner.
Will we be able to fully address this need? Probably not, but continuing the concerted effort will make a difference. When I reflect on the mission I am uplifted by the lives I have been able to touch, fortified by the challenges I have faced, and driven onward by the observed need. It was a great pleasure to work again with a team of colleagues from the past, and new team members all with the unified vision of the Spine Mission. I commend the Uganda Spine Mission for the great opportunity afforded to me to participate in such a great humanitarian effort.
Kirill Ilalov
Having recently moved to Texas and its dog days of summer, in August of 2011 I boarded a plane to Africa to join a team of doctors, nurses and therapists on my journey to Uganda. Not only was this my first ever trip to the continent, but it was also my first opportunity to practice medicine in an indigenous environment of a third world country. I tried to keep an open mind, expecting to be surprised, probably even shocked, see things I only knew from textbooks, and, perhaps, take a trip into the bygone era of medical science. Although all those things turned out to be true, the trip also turned out to be an expedition into the human nature, at times demonstrating how far the limits of human dignity and suffering can be stretched. Especially during those times, it became evident how perseverance of a few dedicated individuals can make a remarkable difference when most have given up on providing even the basic care. I saw some of the most complicated surgical procedures performed with bare-minimum equipment in almost field conditions.
Interacting with the local patients also made me re-experience what I may have occasionally forgotten during the long years or surgical training – why I became a doctor in the first place. Often enough the extent of the patient pathology and lack of available treatment options made the doctor-patient relationship the only tool reliably at my disposal. The only part that was expected of me when interacting with my patients was an expression of my empathy. Patient's “thank you” often made me recall that line of the Hippocratic Oath line that says “warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug”. Providing care in that challenging environment undoubtedly made me much more thankful for what I took for granted at home. However, it also helped me learn my most valuable lesson from this expedition – the importance of trying to do your best with whatever you have at hand in any circumstance you find yourself in.
Selvon St. Clair
This was my 3rd trip with the USSM and by far the most rewarding. Having now completed my spine fellowship, I had the unique experience of ascending to an attending position on the trip. It was humbling to be given that opportunity of graduated independence with patient treatment plans and execution. I am again shocked by the breath and dept of spine pathology; limited resources both non-operative and operative; and learned apathy by the personnel in the forefront of the health delivery system in Uganda.
Further, I had the privilege to operate at a different site- Case Medical Center, which by all accounts, functions at a very high level. They are definitely trying to make a difference by offering a respectable option for Ugandans in need of preventive and tertiary level healthcare. With that said, Mulago should remain an integral part of the mission because the spine trauma patients are in desperate need of high quality surgical and nonsurgical care to prevent the sequelae of paralysis, which is preventable. In addition, Mulago also offers the best opportunity to educate the local health practitioners from nurses to physicians- which is one of the primary goals of the USSM.
In closing, I remain committed to the USSM and plan to continue my volunteering. I look forward to leading an independent team in the winter of 2013.
Kris Siemionow
As it always is, this years’ Uganda spine surgery mission proved to be a very gratifying experience. It did have its share of challenges but I feel that we were better able to address them……or maybe as Kiril put it we just “reset our barometer” and took things as they are. As always, I am amazed by the contrasts. You can see malnourished orphans with scoliosis, eat at a luxurious hotel, and pass by the city slums all in an hour and then find yourself being run off the road by a large Mercedes ferrying some dignitary or maybe stopped at a
checkpoint and questioned. Then there is the flurry of construction with modern high-rise buildings popping up all around the city, I heard that some were funded with gold taken from the Congo. All of this serves as a backdrop to doing some really challenging cases on a few grateful patients. The team really came together this year and I am looking forward to 2012.
Krzysztof Kusza
Participation in the mission as an anaesthesiologist was the most profound experience of my entire medical career of 31 years. It was also — or perhaps primarily — a sociological and cultural phenomenon that deeply affected my thoughts and emotions.
Leaving aside medical work, which, from the point of view of epidemiology of spine diseases and injuries in the country, could not have had any major scientific significance, the mission, due to its timing, allowed a small number of individuals to take this opportunity to provide, under conditions approaching accepted medical standards, decent medical care in situations of immediate threat to human life. In my opinion, the mission could not but leave at least a trace of positive thinking about the future among people of this country and perhaps inspire reflection on the chances of living a better, more dignified life. If a person gets up in the morning only to struggle to survive one more day and, if lucky, eat one meal, one cannot expect that person to be aware of public matters and to be capable of bringing about some change. Though medical in purpose, the mission enabled a keen observer to realize that sometimes simple means may lead to barely imaginable goals. The mission cannot but leave behind some awareness of another world, from which people come to share their knowledge, skills and good will, just like that, from the deep of their hearts.
I realized that the mission in which I took part served not only those who stayed there forever and perhaps will never build a better world. In reality, it is a moot question which of the two worlds is a better one: mine at BMW, or that of the fisherman, who sits for hours on end on the shore of Lake Victoria and has no needs apart from bare survival? In some ways, my life has undergone a re-evaluation and while I work today in a country that belongs to the so-called better civilization, I keep thinking that the value of human life is equally immeasurable, wherever one happens to live. The stress of using equipment of dubious reliability to anaesthetize patients who put so much trust in us inspires my admiration, but also inner rebellion. After all, they are no less important than us – they just happened to be born at the wrong place and at the wrong time. Or perhaps our world would not be acceptable to them? Perhaps they are happy in their world? I am grateful to the organizers of the mission for the opportunity to share my experience and thoughts with my residents in Poland, frustrated with low wages — only $ 36,000 per year — frustrated because they cannot enjoy life and be happy unless they possess material things, and do not appreciate life if it is not in danger of being cut short at any moment.
Thoughts: A perfect team of surgeons in terms of intellect, manual skills and organization. Equipped with medical tools and facilities that allow them to operate at the edge of risk. Anaesthesiologists that have to work with equipment and local facilities that exceed many times the limits of risk and norms accepted in the EU. We would like to change this in the future, being aware that poor anaesthesia causes the so-called late postoperative mortality, which occurs years after the operation, unrelated to the operation itself, but closely related to insufficiently controlled anaesthesia. I believe that we will be able to achieve this goal by strengthening the mission economically and technologically. I am ready to undertake this task.
Most important:
1.I came to trust people who were initially strangers to me and I was able to work with them efficiently.
2.I left behind friends in Africa, patients whom I treated and who I hope enjoy good health, and those who may be facing death due to postoperative complications.
3.I am changed as a man. I look at value systems with greater detachment.
4.I felt I was needed and trusted.
5.I met friends on whom I could rely and who knew they could rely on me.
6.The items listed above cannot be converted to any currency.
A. Sherron Wilson
For the second consecutive year I had the extreme privilege of being a part of the Spine Surgery Mission to Uganda. Several professionals from different parts of the globe, met together in London, united with the single vision of rendering optimum care to the patients we were called to serve. An instantaneous cohesiveness among the team was evident the moment we all donned our "Spine Mission Uganda T Shirts", thanks to Ngozi.
Returning to Uganda held both excitement and anticipation; excitement in meeting and working with ones from the previous year and anticipation in meeting and caring for a new group of patients and families. I was overwhelmed by the reception from the local staff who welcomed us back (veterans) and accepted the new team members.
Conditions at the local Government run facility and the overall infrastructure remain unchanged. There was some disappointment though that at Mulago the Operating Room remained as we left it a year ago with unorganized cabinets and instrument storage areas and boxes of supplies (well intentioned) left unopened and unused.
Patients in the Spine Ward continue to develop huge decubitus ulcers which can be alleviated by educating and involving the family members in the care of their loved ones. Perhaps one consideration for future teams could be the inclusion of either a wound care nurse or a post spine surgical care unit nurse who could deliver hands on care while educating the staff and families at the same time. This could provide huge long-term benefits to the quality of care for all patients and add to the overall success of the Spine Missions.
In contrast expansion and improvements are ongoing at Case medical Center with a large scale building project to include a new Orthopedic Operating Theatre. The staff at Case continue to be supportive, eager to learn and very grateful for any donated supplies.
The dedication and commitment of each team member was not only to care for the patients, to deliver a standard of care deserving of every surgical patient, to provide safe, effective anesthesia with adequate analgesia but also to increase the knowledge and skill of their peers via lectures or hands on practice. We were also privileged to meet a number of individuals who have dedicated their lives to serving on a long term basis in Uganda.
The most memorable lesson that I will take with me is the comment of a young patient who despite her prognosis, expressed heartfelt appreciation for the fact that someone cared enough for her and that made a difference in her life. One person can make a difference and I am extremely honored to have been a part of this great team of individuals serving on the Uganda Spine Mission 2011.
Love means the same in any language or culture. Thank you Dr. Lieberman and Health Volunteers Overseas for this opportunity.
Brian Failla
This recent mission trip was my third visit to Uganda. Much of what was surprising to me on previous trips is now familiar and expected. It is amazing to see the large and small changes that the mission has effected that help to improve the local machine that is struggling to provide spine care in Uganda. Support staff, nurses and surgeons from years past were expecting our arrival and were excited to have us back, mostly. Some view our presence as intrusive, though. We are accustomed to long work days that are finished when the day's tasks are completed not when some whistle blows. And, our culture is quickly paced with a constant sense of urgency to every task. This contrasts to the Ugandan culture which is less...immediate. Perhaps we can learn a bit from each other.
But, so many of the challenges that we have overcome or manage easily at home are still everyday obstacles to reasonable healthcare in this now familiar to me country. It is because of these positive changes and persistent challenges that it is so imperative to continue and expand this and other philanthropic endeavors.
One thing about this third trip that is at the same time familiar and foreign is the people that make it possible. It is inspiring to have again witnessed a group of mostly strangers varied so widely in age, ethnicity, nationality, gender, religion come together so comfortably to work to help others. It's incredible to see individuals so unfamiliar to each other quickly become friends, confidants, mentors, teachers and students. I applaud this collective group of heroes that sacrifice their personal time to help others just because there is a need.
Amy Watson
I was unsure of how this trip would affect me. Although I had prior knowledge about the “Uganda spine mission experience”, there is no amount of second hand information that could have possibly prepared me for what I actually experienced. It is hard for me to believe that people can function, let alone live a productive life in this type of environment. It saddens me that our society in the US can complain about our health care system. I do not believe the US has the best healthcare system, but compare our life expectancy to the people in Uganda- not the same! There is no preventative medicine or routine checkups. It breaks my heart that people do not want more out of their lives (to be healthier). It frustrates me that we meet so much resistance when it comes to following a schedule, orders and medicating a patient. I understand culture but what is the best way to accomplish our goals? Each day I tried to think of how best my talents could have been used; after lots of thinking and strategizing the night before, only to meet a new resistance! I feel there is so much to be done in Uganda; there are so many people in need. I think this group is on the right path of making a difference and I remain honored to have served on the 2011 trip.
Jordan Silverman
The night before our flight to Uganda I tossed and turned in anticipation for the spine mission ahead. Having read previous mission reports, I knew more or less what to expect. But I had also been cautioned about the challenges of medical volunteering overseas: the fear of Westerners, the discontinuity of care, the inability to make a real, lasting impact, and the volunteer’s benefit exceeding that of the patients. These myths were quickly dispelled. We were welcomed with open arms in the clinic, greeted by past patients and swarmed by new surgical candidates. Ugandan surgeons and residents had a keen interest in learning from us and improving their own ability to deliver care. Most importantly, the services and care we provided made a huge difference in the lives of these patients and their families, and their smiles told it all. With the hard work of the many involved, the spine mission is now a sustainable organization that provides necessary and otherwise impossible care to a community with severe need.
I felt very grateful to have been involved in every facet of this year’s trip. I saw patients in the clinic, spent valuable time learning in the operating room, participated in the delivery of the Torah to the Jewish people of Putti and distributed kits of school supplies. As scribe I also had the opportunity to converse daily with the interesting, selfless and wonderful members of the team, learning valuable skills and lessons from them all. I was impressed with how our diverse personalities and experiences resulted in a cohesive team. The mutual trust and respect shared was critical in accomplishing a great deal in our short visit.
Uganda is a beautiful country. The kind people, the lush landscapes and multitude of natural resources make it hard to believe that it is among others in the developing world. The political climate has rendered the health care system deficient, the infrastructure poor and the peoples impoverished; there is real need in Uganda and this can only be adequately addressed through fundamental social and political changes. In the mean time, however, it is our duty to reach out to our fellow man in any way that we can. The spine mission is only one of many ways to empower a nation, and everyone should access their own unique set of talents and skills to make a difference in the world, however small it may seem.
On a more personal note, working in Uganda reminded me of the importance of putting your own life and day-to-day challenges in perspective. On this planet, there are nearly 7 billion human beings, each one equal to the next, but experiencing vastly different worlds. Despite your conditions and material possessions, stepping outside of yourself and focusing on the needs and desires of others provides a much more solid grounding when life decides to throw you a curve ball. Through the happiness of others, I believe that one can achieve a deep and true joy and for this I eagerly await my career as a physician.
Ngozi Akotaobi
In the months leading up to the mission, I fluctuated between feelings of apprehension and excitement as I tried to prepare myself for what would await me in Uganda. Once I finally arrived in Uganda, I quickly realized that my so-called preparation would prove useless.
Because this was the first year to have physical therapy incorporated into the mission, I was determined to lay a strong foundation for future missions. This task began to feel almost impossible, as I struggled to make sense of the abysmal conditions I was witnessing. I was shell-shocked as I walked through the spinal ward at Mulago hospital for the first time. That same feeling came over me when I become conscious of the disparity between the conditions at Mulago and Case Medical Center. With so much to be done, I just couldn’t see how I could possibly make a difference in such a short amount of time.
After about a week in Uganda, I realized that I needed to change my mindset. Our culture is one that promotes immediate gratification and quick results. As a result, I went to Uganda expecting to blaze trails. When I finally discovered what it meant to utilize “slow, gentle pressure”(a “Dr. Lieberman-ism), things began to run a lot more smoothly.
Now that it is all said and done, I feel good about what was accomplished during the past two weeks. However, I find myself struggling with feelings of guilt and frustration over the discrepancy between healthcare here at home and in Uganda. I leave Uganda a better person and therapist as I have learned a new level of compassion and patience. I am extremely honored to have worked with such a dedicated and caring group of people, and I am eternally grateful to have been part of such an amazing experience!
Alex Zapata
Traveling to the other side of the planet was an experience I approached with equal measures of anxiety and excitement. I had no idea what to expect and the fear of the unknown had me on my toes and ready for anything. Now being on the other side of the trip I can confidently say that all of the preparation and anticipation was worthwhile, and at the same time it was partly futile. I learned a lot working with our team, learning from each individual as well as by watching the team work so well together in a variety of situations. As part of my duty was to be the cameraman, my job was to watch everyone and try not to miss the important stuff.
The most important lessons I learned through this trip were that it is all important, so pay attention all of the time. I more deeply appreciate the amount of resources and opportunities available to me than I ever have before, and I am furthermore keenly aware of what others do not have. I am more conscious of how we can all reach out to help our neighbors as individuals and groups of every size. I learned that a handful of people can reach into a distant part of the world and really make a difference in peoples’ lives. It was a hard trip that contained a lot of stair climbing, running, helping and ultimately receiving a healthy dose of reality and I would not trade this experience for anything.
Zbigniew Szkulmowski
1. Organization of the mission (trip, accommodation, apartments, local transport) was perfect.
2. The ambiance in the team was perfect -I was really very glad to have a possibility to work with you and all the members of the team.
3. From the professional side:
- as I could see in the operation book in Mulago hospital, the surgical procedures performed there where rather short: 1 - 1.5 hours. The local anesthetic possibilities were (hardly) adapted for that.
- the long procedures which were performed by the team 6 - 8 hours could not be covered by the local resources. It is possible, with some long and difficult procedures, to exhaust the anesthetic resources of Mulago hospital foreseen by them for a long time and for a great number of patients,
- it can be possible perhaps (and not so expensive, I think) to take all the anesthetic equipment needed for the operations (gases, medicaments, fluids, mainly colloids) by that way the procedures will be safer for the patients,
- for increase the security of the procedures, it would be good to organize the postoperative care in Mulago hospital (1-2 monitors borrowed for the time of the mission, 1-2 local nurses paid for extra duties for the postoperative period),
- We have observed the anesthesia performed by local anesthesiologists in Mulago and we had a chance to talk a bit with the anesthesia residents. I think, we can perhaps have an education program for the residents of anesthesia at the time of the mission?
- perhaps, for the next time, we can prepare an article for the local doctors describing the surgical procedures and the anesthesia and postoperative care adapted for these operations...
Surgery Case List
Aug-10 G.K. 20 M Case T11/T12 fracture dislocation with paraplegia (fell off avocado tree) T10-L1 decompression, reduction, reconstruction and instrumented fusion
Aug-11 N.H. 9 F Case T9/T10 Tuberculosis (TB) kyphotic deformity due to osteolysis T7 to L1 debridement, reduction, reduction, reconstruction and instrumented fusion
Aug-12 G.K. 39 F Case L4 spondylolysis/pars fracture with radiculopathy Posterior L4-5 decompression, reduction, reconstruction and instrumented fusion
Aug-15 P.K. 64 M Mulago C3-4 fracture dislocation with paraplegia (Backward fall) posterior C2 - C5 reduction, decompression, reconstruction and instrumented fusion
Aug-15 A.I. 39 F Mulago L2 burst fracture with incomplete nerve root injury (fell off truck) posterior L1 to L3 reduction, decompression, reconstruction and instrumented fusion
Aug-15 M.L. 63 F Case Degenerative L3-L5 stenosis with claudication L3-5 decompression and instrumented fusion
Aug-16 D.B. 63 M Mulago C3 fracture C4-C5 Bilateral jumped facets with quadriplegia(motorcycle accident) posterior C2 to C6 decompression, reduction, and instrumented fusion Respiratory distress. CPAP applied.
Aug-16 F.K. 22 M Case Congenital scoliosis, previous instrumentation and fusion, misplaced hardware T5 to L5 revision instrumentation, correction and fusion
Aug-17 E.N. 73 M Mulago Deep wound infection, chronic draining sinus, loose hardware, pseudoarthrosis irrigation, debridement and removal of hardware
Aug-17 J.S. 35 M Mulago C45 fracture dislocation with quadriplegia posterior C2 - C5 reduction, decompression, reconstruction and instrumented fusion Fever
Aug-17 A.W. 15 M Case Kyphosis associated with Cerebral Palsy (neuromuscular kyphosis) T3 to L3 posterior segmental instrumentation, correction and fusion Proximal fixation failure requiring revision aftger team left
Aug-18 P.T. 14 F Mulago Congenital scoliosis left-sided thoracoplasty (T3-10), posterior T3-L2 segmental instrumentation, correction and fusion Assisted ventilation required
Aug-18 S. N. 50 F Case C5-6 degenerative stenosis with disc herniation and myelopathy C5-6 Anterior cervical discectomy & fusion (ACDF)
Aug-20 I.K. 64 F Case C7 - T1 degenerative stenosis and spondylolisthesis with disc herniation and myelopathy C7 - T1 Anterior cervical discectomy & fusion (ACDF)
Aug-22 B.A. 7 F Mulago Congenital scoliosis and Pectus Carinatum T7-L3 posterior segmental instrumentation, correction and fusion with multi level smith petersen osteotomies
Aug-23 A.T. 15 M Mulago TB, osteolysis, pseudarthrosis, loose hardware, chronic draining infection Debridement of incision abscess tract, hardware removal
Aug-24 J.A. 20 M Mulago L1 fracture dislocation with complete paraplegia (fell in well) Anterior left sided thoracoabdominal T11-L2 instrumentation, decompression, reduction, reconstruction and fusion
Aug-25 M.M. 51 F Mulago L4-5 degenerative spondylolisthesis with forminal stenosis Posterior L4-5 segmental instrumentation, decompression and posterior interbody fusion
Quotes of the Day
“I’m gonna have to re-adjust my malaria meter.” Ilalov
“Case served us lunch today. The rookies ate it.” Failla
“I wouldn’t have made it through surgery today without that 6 hours of pure PASSION!” Siemionow, with reference to the energy drink
“His name’s not Jonah, it’s JUDAH! Jonah got swallowed by the whale…Judah got swallowed by the village of Putti!” Lieberman
“Being Jewish isn’t about where you were born, the color of your skin, or what your name is. It’s about what you feel: what’s in your heart.” Lieberman
“If I slow down my thoughts I speed up my productivity.” Zapata on keeping up with his video / IT responsibilities
“Zbigniew, are you okay?” “Yes, but the level of caffeine in my organs is very low.” Szkulmowski
“This food………2 CEE-PRO.” Kusza referring to Ciprofloxacin antibiotics used for gastrointestinal distress after viewing the buffet at the African theatre
“The behavior of the Uganda peoples is like video games. They think they have three lives. But this is not true. They have only one.” Kusza on the whimsical attitudes and reckless standards sometimes encountered in the equipment, protocols, and patient care guidelines in Uganda’s health care system.
“Man, Face book is BLOWING...UP....” – Alex, on social tensions at home
“I’ve eaten termites before. They taste like carrots.” – Kirill
“If I could have a 2nd Ugandan wife...she’s the one!” – Arne
“Oh you’re pregnant? Do you know who the father is?” – Brian, to sister Rose
“A mask, professor? But please...finish chewing your food first.” - Kris to Jordan upon entering the O.R.
“Oh good. I can actually do this surgery.” – Lieberman, 3 hours into a tough procedure
“She fears the sight of big blood because she’s a paediatric surgeon.” Assistant to the Head of Mulago hospital
“In the military and at Mulago hospital, there is no such word as ‘please’.” Dr. Raymond Malinga
“God blessed the African woman with good sitting facilities. We also call it a trailer – one moves while the other is trailing behind.” – Ugandan cultural show
