Uganda Charitable Spine Surgery Mission

Uganda Spine Mission 2011

2011-10-08T14:32:00.000-07:00

TRIP REPORT

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.

Figure 1; from lt - rt, back row, Lieberman, Siemionow, Silverman, Failla, middle row, Kayanja,
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.

Figure 2; the Liebs contemplating how many days he can make the same pair of underwear last

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.

Figure 3: The Spine Ward at Mulago

Figure 4: the Penalty Box waiting room

Figure 5: Scars from bloodletting to release demons from deformed spine

Figure 6: An Israeli flag hangs mysteriously in the trunk of a parked vehicle.

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.

Figure 7: warehouse with the VeAhavta shipment being sorted

Figure 8: Patients from the orphanage with their Kinder Kits.

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.

Figure 9: Ngozi, our physical therapist, working with a patient.

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.

Figure 10: Brian, the team’s equipment manager, scrubbed in during surgery

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.

Figure 11: The congregation rejoicing over the arrival of the Torah scroll

Figure 12: All the kids in Putti with their new Kinder Kits. Red looks good on the village

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.

Figure 14: sorting through Sister Sarah's storage closet

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

Uganda Spine Mission July/August 2009

2009-10-04T15:19:00.000-07:00

Uganda Charitable Spine Mission
July 26th-August 7th 2009
Trip Report

http://www.firstgiving.com/UgandaSpineSurgeryMission2009-2010

Team; Isador Lieberman MD, Mark Kayanja MD, Selvon St.Clair MD,
Donna Sustar, Brian Failla, Michael Silverstein

Location; Mulago Hospital, Kampala

Society Sponsors; Health Volunteers Overseas (Orthopedics Overseas), Scoliosis Research Society (Global Outreach Program)

Corporate Sponsors; Medwish Inc, Globus Spine Inc, Synthes Spine Inc

Local Physicians Dr. Deo Bitariho (orthopedics-Mbarra),
Dr. Malan Nyati (orthopedics-Mulago),
Dr. Geoffrey Madewo (orthopedics-Mulago),
Dr. Titus Beyeza (Chief Dept. of Orthopedics -Mulago),
Dr Emanuel Munyarugyero (anaesthesia Mbarara)

To whom it may concern,

The 2009 Uganda Spine Mission Team with gratitude and anticipation for the future, respectfully submit this trip report outlining the accomplishments and details of the July/August 2009 trip.

We would like to first acknowledge the support of the many, who with their contribution allowed us to once again accomplish so much; Globus Spine Inc. provided the full breadth of instruments and implants to allow us to treat the entire spectrum of spine pathology, Medwish Inc. was yet again a source of vital medical equipment which proved indispensable during this mission, The Operating Room Personnel and Hospital Staff at Cleveland Clinic Florida were dedicated to collecting discarded items for use in Uganda, All our generous friends and family who took the time to generously donate to the mission via the website, and as always, the staff at HVO and the staff at SRS who were active supporters and a pleasure to deal with.

This team consisted of the veterans (IHL, SStC & MK) and the rookies (DS, BF, MS). There was a clear distinction in emotions and anticipation between the two. The veterans knew what was ahead and hoped for a productive yet uneventful mission. The rookies were eagerly curious to determine if the stories and experiences they heard were true. Once entrenched in the work flow, the entire team gained in their unique way a sense of purpose, dedication, insight into their own personalities, their own beliefs and fully experienced the devastation of neglected spinal pathology and the extent of care needed.

In retrospect this mission was by far the most productive, most organized, and seemingly best accepted by the local medical establishment. At Mulago hospital the dedicated spine ward and operating theatre were open and functional. Still limited by North American standards, however, clean, sound and well equipped. Despite the new facilities we once again encountered limitations of time, of equipment, and of personnel. The issues of sterilization returned to hinder us over and over due to the lack of fresh water for sterilization. Regardless, the prevalence of treatable spine pathology (neglected trauma, acute trauma, spinal infections, spinal tumors, spinal deformity and degenerative conditions) was excessive, and the need for comprehensive spine care, overwhelming. The team took the challenge and each member functioned admirably keeping their utmost regard for the patient’s well being.

Arrival (July 26, 2009)

The team began the journey split, half coming from Fort Lauderdale and the other half from Cleveland. Initially, we were to meet in Detroit and travel together to Amsterdam, where we had a connecting flight to Entebbe. Due to weather issues in Florida, the group met in Amsterdam instead. But, after more than 20 hours of traveling, we arrived in Uganda with excitement and anticipation for what was ahead. The city reminded a few members of the group of something they had seen on the Travel Channel. Upon arrival to the Golf Course Apartments, we unloaded the vehicle and established a plan for the first day.

Day 1 (July 27, 2009)

The day started off with a breath of fresh air and an early breakfast. Surrounded amongst colorful scenery, the team enjoyed a breakfast of fresh orange juice, pancakes, egg whites and coffee. After we had some fuel for the day, we loaded supplies in the van and headed to Mulago Hospital to set up for the day.

We meet with Dr. Titus Beyeza, Head of the Orthopaedics Department. He welcomed us with a warm smile and was happy for us to be there to provide help as well as educational opportunities. Both the veterans (IHL, MK, SStC) and rookies (BF, MS, DS) spoke with Dr. Beyeza about their excitement for being able to help the community. Dr. Beyeza explained to the team that there has been an increase in interest amongst the residents in pursuing spine surgery as their field of specialty. This made the desire to provide education even more personal. To educate future spine surgeons in Uganda is a key component of our mission.

Following our meeting with Dr. Beyeza, we proceeded to the newly opened spine ward, where we inspected the recently opened operating room dedicated to spine surgery. (See Figure 1) Bolstering our enthusiasm was the fact that the operating room looked functional clean well stocked and ready to use. We then moved on to the spine ward to visit with patients ranging from young children to the elderly. We quickly established a plan of action for those patients that were deemed operable and others that would recover better with rehabilitation.

Figure 1: Inside the new Spine Ward. Standing (L to R)- Silverstein, Lieberman, Sustar, Kayanja, St. Clair, Failla

After seeing patients in both the ward and clinic, half of the team triaged the patients for surgery for the first week while the others began sorting out the instruments for surgery. There were already 14 surgeries scheduled. Both the new Spine operating theatre and the Old Mulago Orthopaedic operating theatre would be used to perform surgery. The tentative plan included surgery in the Spine OR on Tuesday through Friday and the Orthopaedic OR on Wednesday and Thursday. The equipment and patients would have to be shuttled back and forth between the two sites.

The first day brought emotions of both excitement and regret to the team. Patient B.N. had surgery by the team that came in March 2009 to correct his scoliosis of 110 degrees. He was very happy to have had the surgery and showed a quick recovery. A thoracoplasty (further resection of protruding ribs) would be planned for next year. On the other hand, two young patients who were planning on coming to Mulago Hospital for assessment and surgery, from the Children’s Home, were informed that surgery would not be an appropriate option for them.

Another patient we saw during clinic was N.K., a 14 year old male. He had Pott’s disease (tuberculosis infection of the spine) that had wreaked its damage and can not be corrected with surgery. Performing an operation on him would only increase his chance of death without greatly improving his quality of life. At this point in his life he was still able to play sports and keep up with his friends. (See figure 2)

Figure 2: Patient N.K.

As our time at Mulago hospital came to an end for the day, we quickly were reminded of just how precious life is and how a worldwide effort is needed to alleviate the suffering from debilitating spinal illnesses.

A short drive back to the apartment turned into a journey of despair. The veterans quickly noticed the increase in the volume of cars and resultant traffic in Kampala over the four previous missions. Apparently many discarded vehicles from Europe and North America are being shipped to Uganda and are available relatively inexpensively compared to used vehicle prices around the world. The combination of vehicles, animals (cows and sheep), boda bodas (scooter taxis) and no traffic signals or stop signs combine to make driving in Kampala a whole new life threatening experience. Despite the harrowing 1.5 mile drive back we ended the day with a refreshing dinner, and tall tales, which went late into the night.

Day 2 (July 28, 2009)

This was the first day of surgery at Mulago hospital. Two were scheduled for the spine theatre (Patients G.M. and S.N.). Dr. Lieberman presented an instructional lecture on adult spine trauma to the residents and orthopedic professors of the medical school. While he was speaking the team was quickly trying to organize the medical instruments and supplies for the scheduled surgeries. Preparation of some of the supplies were delayed due to the common water issues which have we experienced during our past missions to Mulago hospital. Once the water became available, the autoclave was run to sterilize the instruments for the day. This delayed us somewhat and we did not begin the first surgery until about noon. This would have a lingering effect.

Patient G.M. was the first patient to undergo surgery. Patient G.M. was a 60 year old man who has been bedridden and suffering from severe back pain for the past few months. He was started on medication for TB the previous week. The MRI scans that were reviewed, revealed an epidural mass at the T12 region of the spine. The surgery lasted 5 hours and consisted of a T10 thoracotomy (removal of rib), with an anterior T12/L1 release, decompression and reconstruction. His rib was used as a bone graft to fill in the cavity. There was not a large amount of blood loss during the procedure. The mass that was removed was sent off to pathology and it was predicted that patient G.M. had either TB or some other spinal osteomyelitis (bone infection). On day 1 post-op, the patient stated that he was not in much pain but he still had some drainage from his chest tube. Even though he was bedridden, he had a large smile, and was enthusiastic about his treatment and prognosis. (See Figure 3) He was instructed on the use of an incentive spirometer (a breathing exercise device, supplied by Medwish) and to sit up in bed. A few days later he was able to move to a wheelchair.

Figure 3: Patient G.M. (L) Being examined by Dr. Isador Lieberman,

In between our surgical cases of the day, patient K.N. was brought into the spine ward to be seen by the team. She was a 54 year old female that was in a motor vehicle accident and paralyzed due to a severed spinal cord at T10. As her spine was unstable the prescribed treatment for K.N. was a reconstruction and fusion with rods and screws from the T9 to L1 spinal levels.

The second surgery of the day began in the early evening following our first case. Patient S.N. was a 35 year old female that was diagnosed with congenital scoliosis. She stated that the lower back pain she has been having for a good portion of her life has gotten progressively worse in the past 7 years. For the past month, she has been unable to move her legs. An epidural abscess was found at the 8th thoracic level. During the surgery, a unilateral hemi-laminectomy was performed from T7 to T11. In addition, a T8 biopsy was taken to identify the abscess. Post-op on day 1 she stated she had a burning sensation in her legs and was still unable to move her legs. The results from the pathology lab had not yet returned by the time we left Mulago Hospital, so the doctors from the hospital would contact us when they received the results.

Day 3 (July 29, 2009)

Prior to this day’s scheduled surgeries, we saw a few new patients who heard we were here in town to provide care. Patient A.A. was a 19 year old male who had surgery during the last mission trip in April 2009. He had a fusion at L4-5 for spondylolisthesis. One of the screws was creating some pain for him, but he is still in the recovery phase from his surgery. It was planned for him to follow up with the team in a year to reevaluate him then.

Unfortunately for the two other patients we saw that morning, surgical treatment was not an option. Patient S.D. was a 3 year old female who was diagnosed with kyphoscoliosis. The team of doctors decided to follow up with her next year to see if her condition has progressed. The other patient, E.M., was a 33 year old female with pain throughout her arms and legs along with difficulty walking. Due to her myopathy (muscular disease) not coinciding with a spinal condition, a metabolic or rheumatologic disease was suspected. She was advised to see a rheumatologist and get tested for a vitamin B12 deficiency.

The first scoliosis case of the trip was rewarding to both the team and the patient. J.B. was a 15 year young female with a progressive idiopathic scoliosis. Her curve measured 40 degrees and had progressed steadily from 2005. The proposed treatment was a T6-L1 posterior instrumentation correction and fusion. The surgery took about 6 hours to complete and resulted in a significant correction with no peri operative or post operative complications.

The afternoon case was a 17 year old female whose planned surgery involed two stages. Patient A.N. had a severe case of scoliosis with a 105o right-sided curvature. This left her with a drastic curvature and limited her daily activities. The first stage consisted of entering through the rib cage (going from in front) and releasing the vertebral bodies of T7 to T10. The second stage would occur the following week to correct and stabilize the spine from behind.

Day 4 (July 30, 2009)

The first surgical case of the morning was pushed over from the previous day due to time constraints and unsterilized equipment. J.K. was a 7 year old female patient that was diagnosed with congenital scoliosis. The surgery did not require instrumentation, but used her own bone and growth potential to realign her spine over time (in situ fusion). J.K. was a real trooper! She handled the surgery very well for her age.

Our next case was a 19 year old male, G.M., who was complaining of mostly leg with some back pain. His symptoms were a result of his congenital (born with it) stenosis (narrowing of the spinal canal) and a chronic disc herniation at the L5/S1 spinal level. A laminotomy and microdiscectomy was performed to correct his problems. He handled the pain well but his body habitus was a major limitation to his rehabilitation.

Throughout the trip we encountered many unfortunate patients who we just could not help. Patient A.T. was a 4 month old female that has both neurological (brain) and spine problems. She had travelled with her desparate mother from one of the distant villages. The cause of her symptoms is simply not known and at this young age her prognosis for any meaningful function is limited. We recommended she return in one year for further evaluation.

Day 5 (July 31, 2009)

Today was a very rewarding day for the team and patients. The day began with checking the post operative patients on the spine and orthopedic wards. All of the patients were doing very well following their surgery and neither the patients or the team had encountered any major issues. During this visit we did however notice how the local nursing staff are reluctant to dispense any pain medications. The prevailing sentiment is that using pain medication will cause one to become addicted. The team had a difficult time understanding the sentiment especially knowing the extensive nature of the surgeries we performed. In response we made arrangements to have medications dispensed either by the team or by the family members on a regular basis.

That afternoon we evaluated yet another testament to the human resilience. A.W. accompanied by his father came to the spine ward to be evaluated. A.W. is a 16 year old male that had a severe form of scoliosis that was deemed inoperable. (See Figure 4) Despite his disfiguring spinal deformity he was still able to be physically active and keep up with his friends. His prognosis however is limited, with a small likely hood of survival into the 40’s, and progressive deterioration due to lung and heart issues from compression in the chest cavity due to the spinal deformity. We plan to continuously monitor him.

Figure 4: Posterior view of patient A.W.

The first case of the day was S.K., a bright 18 year old female that suffered from idiopathic scoliosis. Her curvature was corrected from T4-T11 with posterior rods and screws. When we first evaluated her, her main concern was “I just want to be normal and dance”. The team was touched by her simple request and were gratified to see how encouraged she was after the surgery. The surgery lasted 6 hours, and went smoothly. She was discharged from the orthopedic ward 5 days later without any complications and an excellent correction. (See figure 5)

Figure 5: Patient S.K. post-operation image.

The second surgery of the day was performed on patient K.N., the previously mentioned woman, who was in a motor vehicle accident that resulted in paraplegia. The surgery stabilized the fracture by placing rods from T9 to L1. This was successful in alleviating her pain.

Day 6 (August 1, 2009)

Prior to the start of a long but successful surgery, the team completed their rounds of the patients recovering on the wards. All of the patients were doing well with no complications. On the spine ward one of the patients returned with the MRI scan we asked him to get. This patient, R.W., was a 6 year old male that was in a “freak” accident. According to the father he had fallen from a tree and has been unable to walk, feel his legs or control his bladder or bowel function since the fall. After our initial evaluation and review of his x-rays we were lost as to the cause of the paralysis as there was no evidence of a spine fracture. As such we sent him for the MRI scan. As we reviewed the MRI scan the remaining history was then described to us. Apparently R.W. had fallen directly on a board with a nail sticking out of it. It was clear on the MRI scan that the nail had punctured his spinal column and severed the spinal cord at the T8 level. (See figure 6) There is no surgical procedure that will correct this truly unfortunate injury. We were all astonished and disappointed, but no where near as disheartened as his father. All the struggles of Ugandan’s were clearly evident on his father’s face when he was told we could not help him.

Figure 6: MRI showing nail track and photo of nail puncture site.

The surgical case for the day was P.T., a 10 year old female with focal kyphosis (forward bend) of the thoracic spine. The surgical procedures included a pedicle subtraction osteotomy (PSO) at T11, segmental instrumentation (screws and rods) at T9 to L1 and posterior instrumentation from T10 to T12. The surgery went remarkably well despite having the Chief of Orthopaedics assisting us and one of the surgeon’s succumbing to a vicious bought of gastro-intestinal distress 2 hours into the case. She was taken to the ICU following the surgery for close monitoring. Within a few days she was walking and her posture dramatically improved.

Day 7 (August 2, 2009)

Sunday was a day of rest with no surgeries scheduled. The team checked on the patients early in that morning, and all were well. As we rounded on the ward we were introduced to a new admission. C.E. was a 47 year old male farmer, with a large family, who was diagnosed and treated for oral cancer 3 years prior, and was also suffering from HIV. He presented with severe back pain and neurologic loss being unable to walk. His x-rays revealed cancer that spread to his spine. This created compression on his spinal cord, resulting in the pain and immobility. We had him scheduled for a decompression in the hopes of alleviating some of his pain and regaining some neurologic function. As we explained to him the issue and proposed surgery his biggest concern was “as a peasant farmer how am I going to pay you for your services”. He underwent his surgery with no complications. As we were leaving later that week he did regain some leg function and had some pain relief.

Day 8 (August 3, 2009)

Some of our patients from earlier in the trip were ready to go home and were discharged today. They were very happy with the results of their surgery and were grateful for what the team was able to do for them. This was the planned day for A.N.’s second stage surgery. This included posterior instrumentation from T4 to L3 for her 120 degree scoliosis. The surgery resulted in a significant correction.

Later that day the team had a surprise visit from Patient S.N., a 15 year old female, which was operated on in April 2008 for scoliosis. She and her mother were so grateful to Drs Lieberman and St Clair. (See figure 7)

Figure 7: Patient S.N. Post-operative image

Day 9 (August 4, 2009)

The day began with rounds at the ICU in the main hospital to check on A.N., who was recovering according to plan. Upon returning to the spine ward to get ready for surgery we saw two other new patients. Patient N.J. was a 35 year old female that was complaining of general lower back pain without pain traveling anywhere in the extremities. Her radiographs did not show anything suggesting surgery as a treatment option. She was told that an anti-inflammatory drug would be her best option along with physical therapy. The other patient we saw was J.S., a 6 year old male, who got into an accident two months ago while playing with friends. After that day he has been unable to walk or control his bowel and bladder. The recent revelation of a nail injury immediately came to mind, but how likely could we see that tragedy again? We instructed the family to transport the child into town for an MRI.

Two surgical cases were performed on Day 9. The first case was a 7 year old boy, patient J.G. who had a congenital scoliosis with a 40 degree curvature. He underwent a fusion from T7 to T12. The surgery resulted in a very good correction for J.G. Even though still a child, J.G. was able to understand his diagnosis and what how his spine would be corrected.

The following case was that of a 3 year old female, P.A., who was diagnosed with congenital kyphosis and scoliosis. She was the youngest patient the team operated on during this mission. She underwent a right T10 thoracotomy (access to the spine through the chest) and an anterior release of the T9/10, T10/T11 and T11/T12 levels. This was followed by a posterior in-situ fusion T8 to L1 (fusion with her own bone and no rods or screws) with the rib beginning used as a bone graft. The surgery went smoothly without any major issues. Due to her age and the complexity of the surgery, P.A. was brought to the ICU to be monitored closely for a few days. Unfortunately P.A. did develop a persistent fluid leak from her chest tube which nesecitated further treatment after we had left Uganda. Thankfully our colleagues are now experienced enough to handle these issues.

Day 10 (August 5, 2009)

During the morning rounds the patients were seen in the ICU, Orthopaedic ward and Spine ward. Many were discharged home today. The incisions were clean, there were no signs of infection, and the pain, if any, was very minimal and manageable outside of the hospital.

Up to today we were privileged to work with Dr Emanuel Munyarugyero (anaesthesia Mbarara) who by no stretch of the imagination is one of the best anaesthsiologists on the planet. Despite the limited resources his skill, patience and compassion provided for a sense of confidence and comfort for the patients and the team.

Despite not having Emanuel today, we were still able to start out a single but albeit extensive case.

The patient R.A. was a 12 year old male with spinal Tuberculosis which resulted in the development scoliosis. The surgery consisted of an anterior release at T10/11, T11/12 with a T11/12 osteotomy and reconstruction with rib. This was followed by a posterior approach for instrumentation and fusion from T8 to L1. Despite the extensive nature of his surgery R.A. recovered remarkably well in the ICU and within two days was sitting up, eating and even walking around. (See figure 8)

Figure 8: Patient R.A. Post-operative image

That day patient J.S. and his parents returned the Spine ward with the MRI. The results of the study showed J.S. like many others had TB of the spine. The fall incident was purely coincidental and was not the ultimate cause of the paraplegia. He will require surgery and as the team’s departure was imminent he would be operated on by the local spine team led by Dr Nyati. (See figure 9)

Figure 9: Patient J.S. Patient in ward

Day 11 (August 6, 2009)

The team split up this morning to get the operating room set up and finish the ward rounds. The first case involved a 7 year old female, D.G., who had a congenital kyphosis. This type of spinal deformity renders the individual at high risk for paralysis with growth as the spinal cord is stretched over the growing hump. The surgery consisted of posterior instrumentation from the T9 to L1 spinal levels, to allow the spine to continue to grow from in front but tether the spine from behind. The surgery went well and she recovered without any incidents.
The last case the team tackled was patient C.E., the 47 year old male farmer who had oral cancer that spread to the spine. He underwent a tumor decompression at levels T12 and L4. Specimens were collected and sent to the pathology and microbiology department for analysis.

After the surgeries were done for the day, the team went to dinner with the faculty and administration from Mulago Hospital. This was a wonderful social event that certainly validated the purpose of the mission and further established the future vision. We all exchanged our thoughts and views regarding the need to provide care and education to those who treat spine pathology in Uganda. It was absolutely the crowning moment of the visit when the hospital chief administrator ensured that we would always be welcome.

Day 12 (August 7, 2009)

August 7th was our last day at Mulago. Dr. Lieberman gave a talk to the faculty and residents about the diagnosis and treatment of scoliosis. Following this informative session, we made our final round to see the remaining patients on the wards. To our gratification everyone was doing well. P.A. was still in the ICU. But the local team had a plan and would update us on her progress.

It is clear that the severity of cases has intensified over the 4 years of visits. It is also clear that the local health professionals are now understanding the impact they can have on relieving pain and suffering due to spinal pathology. Simple things like trauma management and early antibiotics will alleviate so much grief.

Every member of the team was impacted by what they experienced on this mission. It will forever have an impact on the way we, the team, think about life!

Epilogue

Dr Isador Lieberman; After four years of questioning, it is now clear that we are making a difference. This was by far the most productive and gratifying visit to Uganda. I am indebted to the team for their boundless devotion. I am enthused by the fact that others now want to join the effort. Uganda is not the only place that is in need. I encourage anyone with an interest to visit the Health Volunteers overseas website (http://www.hvousa.org/) to find out more.

Dr Selvon St Clair; I returned to Uganda with much less trepidation compared to my first visit. This allowed me to immediately contribute and enjoy the many aspects of the mission. Although, the conditions at Mulago hospital remain rudimentary at best, there were definite improvement in both the working conditions and the management of the spine ward and operating room. I felt that our efforts along with other international orthopaedics missions are truly having an impact on the way orthopaedics, especially spine care is delivered. Of particular enjoyment to me this trip was the opportunity to closely interact with the orthopaedic residents. Teaching the junior residents to expose the spine and co-manage the patients on the wards was extremely rewarding. Finally, unlike the last trip, I left Uganda with a sense of contentment knowing that our Ugandan colleagues were exceedingly enthusiastic to provide outstanding care to the many spine patients that we had the privilege to treat.

Donna Sustar; To say I had reservations about the trip is an understatement. I was scared to the point of nausea, I have never traveled out of the country before and should of started with a simple trip to Detroit. After the initial shock of it all, I jumped in full speed ahead in classic Donna, take charge style. Then something happened to me, I fell in love. I fell in love with the people and the country and the pure act of giving and doing what I loved most helping the people who needed it the most. However, as much as I helped the people of Uganda, they helped me. I learned so much from my trip. I learned how strong the human spirit is, how much joy a piece of candy can bring, and about giving unselfishly. What I took away most from the trip is that my idealist ideas are not wrong, and I am glad I have not given them up like most people told me too. One person can make a huge life changing difference. Now I do LOVE Joint Commission (JHACO) and some of the western practices, but Uganda is under my skin, a part of my soul, and I can't wait to go back!

Brian Failla; After so many months of planning and anticipation, it’s hard to believe that this trip to Uganda is over! I had a mixture of emotions in the time leading up to our departure: pride at having been invited, the pressure of planning & anticipating every detail needed to operate many worlds away from the familiarity of home and certainly a reasonable amount of fear. My experiences there have changed me. When juxtaposed to the difficulties I witnessed in Uganda, I have a renewed appreciation for all the opportunities that we have available to us here in the United States. Things that we take for granted at home like clean water, healthy food, ready and comfortable transportation and even a soft bed are luxuries not available to the majority of the patients and families of patients that I met at Mulago Hospital. I was inspired and humbled by the selflessness of the surgical team. Their drive to not only do, but also teach so that others might do for themselves is amazing. And, although this was a monumental undertaking, it highlights for me how even small gestures can make profound differences to those in need. I am eternally grateful for this truly life-changing experience that I will carry with me for the rest of my life…

Michael Silverstein; As a medical student, I spend a lot of time learning about the disparities in healthcare around the world. We see pictures, hear stories and even listen to talks from doctors that have made the trip overseas to contribute. Yet, nothing can equate to what you see and how you feel when you are actually there providing care. This trip has taught me many things about myself and it will always have an impact on me as a physician.

Photo Highlights

The slums of Uganda

A road side market

The team at work

the world's best anaesthesiologist

3 days post op, patient with Drs St Clair & Lieberman

2008-09-06T18:33:00.000-07:00

Tuesday, May 01, 2007
TRIP REPORT
Uganda Charitable Spine Surgery Mission, March 19th – March 30th 2007

Team; Isador Lieberman MD, Mark Kayanja MD, Kris Siemionow MD, Ehab Farag MD

Locations; Mbarara Hospital, Mulago Hospital, Mengo Hospital, Katalemwa Cheshire Children’s Home

Society Sponsors; Health Volunteers Overseas (Orthopaedic Overseas),
Scoliosis Research Society (Global Outreach Program),

Corporate Sponsors; Medwish Inc, Kyphon Inc, Medtronic Inc, IGN Medical Inc.

Local Physicians; Dr Emanuel Munyarugyero (anaesthesia Mbarara), Dr Stephen Tendo (anaesthesia Mbarara),Dr Deo Bitariho (orthopaedics Mbarara), Dr Geoffrey Madewo (orthopaedics Mulago),Dr Fulvio Franchesci (orthopaedics Katalemwa & Mengo)

To whom it may concern,
It is with gratitude and anticipation for the future that I respectfully submit this trip report outlining the accomplishments of our recent Charitable Spine Surgery Mission to Uganda.
I would like to first off acknowledge the support of many who with their contribution allowed us to accomplish more than we had ever anticipated. Medtronic Inc., once again provided sufficient spinal implants and instruments to treat the entire spectrum of spine pathology. IGN Medical Inc., donated a fully refurbished anaesthetic machine which was sorely needed to replace the (“EMO”) ether anaesthetic machines still in use at Mulago Hospital. Kyphon Inc., provided Health Volunteers Overseas with a charitable donation that covered travel and shipping
related expenses for the team and equipment, as well as patient care related expenses such as the purchase of x-rays, CT scans, analgesic medications and antibiotic medications. Mr Anibal Morales (CCF) found a discarded spinal surgery four-poster frame, and Mr Tony Shawan (CCF) adapted it for us so we were able to safely position patients for major spinal surgery. Dr. John Doyle (CCF) organized the loan of a Glidescope for difficult intubations. Ms Mimi Hable at Medwish was tremendously helpful in sourcing surplus surgical supplies for us to take. Finally, and as always, the staff at HVO especially Maria Trujillo, and the staff at SRS especially Amy Miller, were dedicated and a pleasure to deal with. By virtue of the above outlined support we were able to tackle any and all spine pathology that presented to us. Our only limitation was time. The prevalence of treatable spine pathology (neglected trauma, acute trauma,
spinal infections, spinal tumors, spinal deformity and degenerative conditions) was excessive, and the need for comprehensive spine care, overwhelming.

I would also like to personally thank the members of the team who cared for these patients with selfless abandon. Once again the ever humble Dr Mark Kayanja, was stellar in his organizational efforts. With his boyish charm, Dr Kris Siemionow provided the always needed extra set of hands and was a constant source of comic relief. Despite his unfamiliarity with the ether anaesthetic machines, Dr Ehab Farag overcame his initial anxiety, and was instrumental in teaching contemporary techniques to the local anaesthesiology staff. Much like the 2006 visit we journeyed to Uganda not knowing exactly what to expect. The anxiety was intense and the emotions were mixed. On arrival the most notable difference, this year compared to last, was that the Ugandan medical staff, and their patients, knew who we were, when we were arriving, and were eagerly awaiting us. There certainly was no shortage of spinal pathology. We initiated our clinical activities with a ward round at Mulago hospital. The staff presented to us seven patients, five of whom we agreed needed surgery and two of whom we sent for further workup. Later that same afternoon, we traveled to the Katalemwa Cheshire Children’s Home and examined four patients and recommended surgery for one of them, observation for two others and further tests for the fourth. Apparently due to transport issues four patients were unable to get there on time, so we had organized to see them later that week.

Day two took us to the Mulago operating theatre. Here we started with an 8 year old girl who had a rapidly progressive and rigid juvenile scoliosis that measured close to 100 degrees (see figure below). The plan was for an anterior release and application of traction. This case set the tone for the remainder of the stay. A double thoracotomy (opening the chest) in an 8 year old child can tax even the most sophisticated and best equipped operating room. After trying to sort out monitors and anaesthetic machines we ended up with the ether machine and a manual blood pressure cuff. Somehow we managed to be ultra efficient and thankfully after two hours of
surgery all went well.

The next day found us in Mbarara. The drive from Kampala to Mbarara was exactly as bad as I remember. Roads that would make a Hummer shake rattle and even roll. Drivers that would make a demolition derby look tame. The journey brought a whole new meaning to thrill seeking ride. Regardless, we survived the trip to be welcomed by a clinic of well over eighty patients and a ward packed with almost as many (see figures below). We ended up evaluating twenty-nine patients and it became obvious we had no chance of operating on even half of those who desperately needed something done. Most likely by benign default, I adopted a first come first serve approach. I really struggled with the age old ethical dilemma; who do you pick?

After an initial burst of patient evaluations we had decided to start operating that afternoon, yet there were still patients to see us who had traveled across the country for whom we felt obliged to in the least evaluate. As we prepped the operating rooms these patients and their chaperones were shuttled one by one to the operating room corridor, which is in an entirely different building from the clinic, so we could at least give them an opinion. During surgery that afternoon we resected a tumor from the base of a young girl’s neck and decompressed a severely stenotic (nerve compression causing leg weakness) spine in a 44 year old teacher. During the second
surgery we lost all electrical power. Eventually we determined that the individual in charge of the emergency generator was away and that the generator did not have any fuel in it. Forty-five minutes later after a moderate amount of not so gentle coaxing, an individual ran out to the petrol station to buy some diesel. Thankfully we were able to resume and complete operating with no untoward issues.

On day four we were back in the operating theatre. Our goals were ambitious. We had three cases prepared for surgery; a 54 year old male with a cervical (neck) fracture dislocation at the C45 level and a right 5th nerve root palsy (grade 2 biceps function), a 55 year old female with presumed multilevel thoracic spine collapse secondary to tuberculosis, and a 60 year old male whose x-ray finding were consistent with myeloma (bone cancer), who needed a tissue biopsy as well as a bone marrow aspirate for diagnostic purposes. We addressed the cervical fracture dislocation with a posterior exposure to osteotomize (cut the bone) the facets and reduce (realign the bones) the spine followed by an anterior discectomy (removing the damaged disc) and
reconstruction. I was astonished at how much we really could do with just a single lateral x-ray of limited quality. I was even more amazed at how well we coped after we once again lost electrical power. As it turned out the main power never had returned and the generator used up all of the prior days refueling. Despite the situation’s best efforts to undermine our treatment, on the very following day this gentleman’s biceps function had already improved to grade 3 and his radicular (nerve) pain had resolved. Once done with the cervical case we tackled the 55 year old female with the presumed tuberculosis. She was already paraplegic and gave us a past history of being treated for tuberculosis. Again all we had was a poor quality lateral x-ray upon which to base our treatment. The initial plan called for a thoracotomy and a multilevel debridement and reconstruction. One must always however remember; it may look like a duck, quack like a duck,
even smell like a duck and still turn out to be flamingo. Her T12 collapse just did not fit the story. As we prepared to start I had elected to abandon the thoracotomy for a posterior approach and possibly a costo-transversectomy exposure (exposing the spine from behind after resecting the ribs) for the debridement. As fate would dictate this was a flamingo. On exposure, the tissue and bleeding we encountered pointed to cancer, as opposed to infection. I was deeply troubled by the operative findings, for if I was able to biopsy, or even better, get some form of advanced imaging the whole treatment paradigm would have changed. As we had the tumor tissue exposed, we
did take multiple specimens for pathologic analysis, yet a few days later we were informed that she had no money to pay for the processing or interpretation of the specimen. I am satisfied that I made the correct choice to change course and use a posterior approach. In retrospect, I firmly believe she would not have survived a thoracotomy. However, I am disturbed that I put her through an extensive procedure which really had no chance of making her better and as of now still did not provide a treatable diagnosis. Near the end of the day, I reflected on the lessons learned; 1) trust your instincts, 2) always biopsy, 3) infection rarely skips levels, and 4) just how much you can do in the dark, without suction or cautery, and with a good, sharp Cobb elevator.

Day five was a packing and travel day back to Kampala. As we proceeded to the operating room in the morning to collect our gear there was a line up of patients waiting to be seen. All those we were not able to evaluate the day before. What was I thinking? They would just go back to their respective villages? Dr Mark ended up seeing them as the rest of us packed the equipment and got ready for the spine jolting ride back to Kampala.

Sunday, our sixth day, found us back in Kampala at the Mengo hospital. The only way we were going to complete all the cases we had committed too, was to convince those at the Mengo hospital to let us operate on Sunday. This proves beyond a shadow of a doubt, that no matter where surgeons are in the world, regardless of the day of the week, we are happiest in the operating room. Mark was superb at organizing the surgical nurses and technicians. Even though we compensated them for the effort (that is code for we bribed them away from their families on a Sunday) I am certain, in respect of their “Dr Mark”, they would have worked regardless.
Sunday’s case proved to be the toughest and most intimidating case we took on. “A.R.” was a seven year old child with a smile as wide as the mouth of the Nile river, a three to four year history of spastic paraplegia, and a severe gibbous deformity as crooked as the curves of the Cuyahoga river (see figure below). He underwent a two level thoracotomy, multiple rib resections/osteotomies (cutting and removing rib segments), thoracic vertebra 6, 7 and 8 debridements, corpectomies (removal of the bone), realignment and reconstructions with the rib grafts. As if this was not enough, it was all followed by posterior fourth through eleventh thoracic vertebrae segmental instrumentation and seventh thoracic level laminectomy and decompression. Once in the chest we were amazed at the complete dissolution of the T6, T7 and T8 vertebrae. As I was laboring through the exposure I could not recall a tougher thoracotomy. The total operative time front and back was over 12 hours. It took every surgical “pearl” I know and even some newly invented ones to get through this case (see figure below). “A.R.” proved to me the absolute resilience of the human spirit. Despite the extensive surgery and an initial stormy post-operative course he always smiled when we saw him. Eventually we determined that he in fact had a gram negative osteomyelitis (that is code for real bad infection) and not tuberculosis so we needed to get him appropriate antibiotics which the family could in no way afford. He remained spastic after surgery, and only time will tell if he is ever able to walk again. In the least, his effort and ours provided him with a stable straight spine.

Monday took us back to the Mulago operating room. We were now in rhythm as a team. After a coordinated setup and anaesthetic we undertook to reconstruct an L1 (first lumbar vertebra) “burst fracture” (see figure below). This was performed through a left sided extracavitary approach with L1 corpectomy, reconstruction and stabilization from T12 to L2. The procedure went as smoothly as could be expected, with minimal blood loss. The patient had a left sided lower extremity paresis and right sided lower extremity grade 2 weakness.

The following day her right leg strength had improved, the paresis remained static up to our departure. While we were operating the refurbished anaesthetic machine was delivered to the hospital amidst significant fanfare. Despite not having a pry-bar or screw driver, the local maintenance crew and the delivery team “tore apart” the crate and wheeled the new prized possession into the theatre block (see figure below).

As we gained confidence and experience we decided to divide the daily responsibilities. Tuesday morning we split the team. Kris went to Mulago to see the patients and get the OR ready, while Mark and I went to Mengo to see the post-op patients. When we returned to Mulago, Kris and Emanuel had our case, a seventeen year old female with idiopathic scoliosis, asleep, positioned and prepped. For her we undertook a posterior segmental instrumentation correction and fusion from T3 to T12. Despite a rigid curve initially and “granite” like bone the correction was substantial.

Again Wednesday we split responsibilities to cover the territory as efficiently as possible. The days case, lined up for Mengo hospital, was an unfortunate young man who was struck in the back of the neck with a log resulting in C4 C5 C6 complex burst fracture dislocation and a dense C5 (fifth cervical level) paralysis. He had just a flicker of biceps function, weak deltoid function and was in bed for 10 weeks with no traction on a poor mattress resulting in full thickness bedsores (see figure below). We had set him up in traction prior to our trip to Mbarara so he was stretched out and better reduced by the time we got him to the OR. For him we proceeded with an anterior C5 corpectomy, decompression, reconstruction with iliac crest strut and stabilization with a cervical plate from C4 to C6. We then flipped him for a posterior C4 to C6 lateral mass fusion and stabilization. We achieved an excellent re-alignment. As we had expected, the dura was shredded by the initial injury as we visualized nerve rootlets from behind. To my surprise though, we did not encounter a cerebrospinal fluid leak which I suspect was a reflection of the chronicity of the injury. Even more to my surprise was the dramatic recovery of biceps function
the following day. He progressed from a grade 2 flicker to a grade 3 contraction now being able to at least get his hand towards his mouth.

On our final day of surgery at Mulago hospital, confidence dictated that we run two rooms. We had one of the local surgeons, one local anaesthesiologist and two of the residents willing to help as well. In one room we undertook an open biopsy of a presumed infection in a patient with a three month history of T10 level paraplegia. All we had to go on was a poor quality x-ray with a significant peri-vertebral soft tissue shadow extending from T10 to T12. For him we performed a left sided T10 and T11 hemilaminotomy (removal of bone to expose the spinal cord) to explore the epidural space, and extended that into a costo-transversectomy to obtain biopsies of the peri-vertebral soft tissue mass. After all was done the epidural space had some thick granulation tissue, however the peri-vertebral mass looked cancerous. The bigger case of the day was part two of our girl with the juvenile scoliosis who spent the last seven days in traction . Her post-operative course after the thoracotomy was remarkably easy for her. She tolerated the traction and her family vigilantly had her exercising and doing deep breathing maneuvers.
Thankfully the anterior releases and traction provided us with significant correction that we were able to improve upon even more with strategic posterior releases and segmental instrumentation and fusion from T2 to L2. We had used a combination of hooks, sublaminar wires and pedicle screws. We also performed a sixth through tenth rib thoracoplasty (rib removal) to assist in the correction and provide bone graft. During the initial thoracotomy we
strategically osteotomized the ribs but left them in place so upon our return all we had to do was slide them through the periosteal (tissue surrounding bone) sleeves into the midline wound. On completion we were very satisfied with the correction, which we estimated to be down to a 30 degree Cobb angle from close to 100 degrees. Best of all, despite my anxiety, post-operatively, she was neurologically intact. This was one case where I would have relished any form of neurologic monitoring.

Friday in Mulago started with a scoliosis etiology and treatment lecture that I had prepared for the resident staff. The group was attentive but they did not seem to immerse themselves into the session. Most interesting was at the end of the lecture there were no questions, yet every one of them pulled out their memory sticks and asked me for a copy of the slides. Later that day we had the official “handing over” ceremony of the medical equipment and anaesthetic machine. The hospital administration orchestrated a small tour for the media personnel who attended. The speeches were diplomatic and highlighted the plight of health care in Uganda. The appreciation of the administration and medical staff was most sincere.

An absolute highlight of the trip was seeing two of our follow up patients from last year’s trip. One was a paraplegic from TB who had undergone an anterior decompression and reconstruction at T12. When she returned to clinic, she walked in with no evidence of myelopathy (spinal cord compromise), and a spectacular smile. The second was a school teacher who we had diagnosed with myeloma, who was also paraplegic . He too underwent and anterior reconstruction. He has recovered enough spinal cord function to walk with a walker and is well underway with his myeloma treatments.

On one hand, for myself and I am certain for the team, providing spine care in Uganda was most gratifying. On the other hand, leaving so many patients uncared for was devastating. The people of Uganda are remarkable. In defference to North Americans they have absolutely no sense of entitlement and do not seem to adhere to any dependant behavior. They are amazingly appreciative of anything you can do. Even something as simple as acknowledgement of their predicament is graciously received and respectfully accepted. I found the people and patients to be spectacularly resilient to social and physical stressors, ably adapting to overcome any obstacles. There was never a question of how to adapt or why to adapt. The medical staff with whom we had worked, were a pleasure to deal with. It was clear that they were limited in their scope and expertise. This however, does not necessarily translate, under most circumstances, to lack of compassion or care. What may be construed as lack of compassion is a reflection of medicine in Uganda being practiced with a paternalistic approach. This by contemporary North American standards is clearly no longer acceptable. We did interact with a few “pockets” of ambition, particularly some of the medical house staff who were eager to participate and learn.
After the May 2006 mission I debated the merits of these missions. Are we upsetting the balance? Are we introducing false expectations? Are we doing any good? Many have asked me, with so much prevalent pathology do you think you are really making a difference? This year I realize what we are doing is far less than a drop in the ocean. I am however convinced that we are making a difference. My hope is that by helping one, he or she can then help two, they can then help four and soon we shall have a wave.

Respectfully submitted,
Isador Lieberman MD MBA FRCSC
Uganda Charitable Spine Surgery Mission Summary

Highlights
1) Delivery of all the equipment as planned and only slightly behind schedule
2) The hospitality of the professional staff
3) The gratitude and affection of the patients and their families
4) Follow up from last years patients
5) The recognition of the Charitable Spine Surgery Mission by all involved as a vital and sustainable program

Accomplishments
1) Donation and delivery of a refurbished anaesthetic machine for exclusive use in the Mulago Hospital Orthopaedic operating theatres
2) Donation of adequate spine surgery implants to tackle the most significant spinal reconstruction cases
3) Over seventy patients seen in evaluation
4) Eleven patients received surgical care over twelve operative sessions with no major complications
5) Twelve patients have been triaged for surgery for the next mission, principally paediatric and adolescent idiopathic and congenital scoliosis

Future Goals
1) Establish a permanent surgical base
2) Establish a quarterly spine team presence
3) Contribute to the education mandate of the Mulago hospital orthopaedic training program
4) Establish an independent tax exempt charitable foundation to support this mission in perpetuity

2008-09-06T18:05:00.000-07:00

patient with broken neck in traction

the ravages of spinal tuberculosis

on the way to the x-ray unit

the operating room team at work

transporting spine surgery equipment

the intensive care unit

the general ward

the paediatric ward

Wednesday, June 07, 2006
Uganda Trip Report,
Spine Surgery Camp, May 12 – 26, 2006
Team; Isador Lieberman MD, Mark Kayanja MD, Mary Kay Reinhardt RN, Danielle Lieberman
Locations; Mbarara Hospital, Mulago Hospital, Mengo Hospital, Katalemwa Children’s Hospital
Sponsors; Health Volunteers Overseas, Orthopaedic Overseas, Medwish Inc, Medtronic Inc

To whom it may concern,

It is with respect and pride that I submit this report of the Spine Surgery Camp.
At the outset on behalf of the patients of Uganda and the Spine Surgery team I would like to thank Kate Fincham, Dr. Denzel and the whole Health Volunteers/Orthopaedic Overseas staff for their support of this trip. I would like to acknowledge Medwish Inc. and Medtronic Inc. for their generous contributions of equipment and implants used during this venture. I would like to personally thank Mary Kay Reinhardt and Danielle Lieberman for their voluntary efforts during this endeavor.

I also extend my most sincere thanks to my colleague and friend, Dr Mark Kayanja for his relentless efforts in organizing this Spine Surgery Camp. His local knowledge, dedication, resourcefulness and organizational skills ensured the success of this inaugural project.
The purpose of this first trip was to introduce the spine team to Uganda and to introduce the Ugandan health infrastructure to the spine team. The introduction will serve as a foundation for future trips and establish a network of collaboration for teaching, research and clinical care of patients with spinal pathology. In this regard the trip was a great success, as the team has already began planning the next visit.

As this was the first Spine Surgery Camp we arrived with much anxiety and anticipation. The first issue we wanted to ensure was that we not leave disasters in our wake. After having done the first ward round with Dr. Beyeza and his team on ward 2C it became obvious that we could improve the plight of some of these patients. The care of spinal trauma, osteomyelitis/discitis and spinal deformity were all far below contemporary North American standards and even basic standards. The second potentially limiting issue concerning our team was the availability of spine surgery equipment. Thankfully between the efforts of Mark Kayanja and the contributions of Medwish and Medtronic we were exceptionally well supplied to essentially handle any spine surgery reconstruction, anteriorly or posteriorly, from the base of the skull to the tip of the coccyx. With our anxiety relieved we marched into the weeks ahead.

On our first day in the Mulago hospital a number of cases were presented to us. Contrary to what I had expected (an abundance of congenital spinal deformity) the cases were late trauma, chronic infections and an assortment of diagnostic dilemmas (neurologically compromised kids with no apparent structural spinal abnormality). Out of the initial lot we planned for three of the patients to eventually have procedures.

After familiarizing ourselves with Kampala and the Mulago Hospital we collected our gear and journeyed to Mbarara (the drive from Kampala to Mbarara is not for the faint of heart). Here at the Mbarara University of Science and Technology and at the Mbarara Hospital we met up with Dr. Deo and the local orthopaedic team. We ran an initial out patient clinic followed by a ward round which again presented us with a multitude of varying spinal pathologies from which we triaged many patients for surgery. Four of which ultimately had surgery; A 59 year old gentleman with a 6 month old C6C7 fracture dislocation with dense paraplegia, a 9 year old boy with spinal TB, respiratory and neurologic compromise, a 41 year old woman with spinal TB and neurologic compromise and an 82 year old male with stenosis and an arthritic right hip. We were able to organize three of the surgeries in Mbarara. We undertook a C6C7 anterior decompression, reduction and reconstruction, an anterior T12 debridement and reconstruction, and an anterior followed by posterior decompression, reconstruction and stabilization for the 9 year old boy with spinal TB. The gentleman with stenosis was sent to Kampala for consideration of hip versus stenosis surgery depending on what equipment we had available.

The Mbarara hospital is as much of a cottage hospital as you can imagine. It consists of separate bungalows connected by covered walkways. The facilities were cramped and in disrepair. The operating theatres were clean, however the equipment was aged and lacking in maintenance and repair. There were no intra-operative portable or c-arm x-ray facilities. The OR lights were not functioning, the back up portable OR lights were weak and there was a severe lack of surgical linens, sheets and gowns. We resorted to using the "bubble wrap" from our shipped equipment to adequately pad the patients during surgery. We found that the hospital recycles the suction tubing which is only 4 feet in length and the cautery hand piece by sterilizing them in gluteraldehyde. The sterilization process certainly had something to do with the persistent malfunctioning of the cautery. After two full and long days in the theatre I began questioning myself and the purpose of the Spine Surgery Camp. Are we really making a difference? Are we premature in our efforts? Are we causing more harm? On the day of our departure when we saw the satisfactory results of our surgical intervention it became clear that we can make a difference. The woman with TB moved her legs for the first time in 4 months, the gentleman with a broken neck sat propped up in bed for the first time in 5 months and the child with the Pott’s disease had a tremendous correction. At the Mbarara hospital, I was most impressed with our anesthesiologist who was able to tackle these complex cases, and monitor the patients in the makeshift "ICU" with only the barest essentials of anesthetic and monitoring equipment.
On our return to Kampala we had a single case scheduled for that day at the Mulago hospital. This was a 60 year old male with an osteolytic lesion of T10. He was in the hospital for approximately 8 weeks with no effective care, a progressive myelopathy with bowel and bladder dysfunction and only a partial workup. The presumed diagnosis was tumor or spinal TB. He underwent a T8 thoracotomy corpectomy, rib reconstruction and anterior instrumentation from T8 to T12. The final pathology revealed the lesion to be a plasmacytoma. Once again the anesthesiologist was brilliant, maintaining the patient’s hemodynamic and ventilatory status with just the minimum of equipment and manually bagging the patient (with one lung retracted due to the thoracotomy) for the entire case.

The Mulago hospital is considered the flagship hospital in Uganda and is the Makerere University Medical School’s teaching hospital. Even though the physical plant was far better than the Mbarara hospital, Mulago suffers from all the typical issues of a teaching institution. We happened to be visiting during the resident’s exam week so house staff and the ward care was non-existent. During the brief encounters with the house staff we did get the impression that they were lacking direction and structure to their responsibilities. The wards themselves were also cramped, understaffed and lacking essentials such as mattresses, towels and linen.
This same afternoon we traveled to the Katalemwa Cheshire Rehabilitation Home to participate in a clinic. This is a charitable institution run by the Christian Blind Mission which provides rehab services to disabled children. We had met up with a wonderful staff including Dr Fulvio Francheschi. They had a number of patients organized for us to review, each of which I felt we could help in some way. We did send three patients for further investigations including CT myelograms. One child was 14 with a 5 month old C3C4 fracture dislocation and partial cord injury.

After one day off traveling to the Bujagali Falls and the source of the Nile we resumed activities at the Mulago and the Mengo hospitals. The Mengo hospital is a combination public private institution. Some areas were very well appointed by Ugandan standards, the others were cottage type wards reminiscent of Mbarara. The theatres at Mengo were however spectacular; a by-product of the Dr Norgrove Penny era. They were clean, well appointed and well equipped. The only thing that surpassed the benefits of these theaters was the staff. The nursing and OR staff were the best yet. They were ecstatic to see their friend and colleague "Dr. Mark" and were enthusiastic, accountable, and eager to work.

During this week, we had 4 more cases primed for surgery over a three day period; An 18 year old female with a C6 burst fracture, incomplete spinal cord lesion and bilateral C7 radiculopathies, who we treated at Mulago, a 14 year old boy with a C3C4 fracture dislocation and dense myelopathy, a 26 year old male with an L1 burst and conus injury, and the 82 year old male with stenosis, the three of which we treated at Mengo.

Our initial plan called for treating the 26 year male at Mulago, however his care was compromised by the system virtually every step of the way. He was meant to get a pre-operative CT scan which did not materialize due to a combination of house staff inexperience and a lack of funding. By virtue of Mark’s efforts the CT scan got done on a Saturday afternoon. He was meant to be operated on as a second case on day one in the OR, however due to an unexpected late start and a less than motivated anesthesiologist he did not get his surgery that day. Again due to Mark’s resourcefulness and efforts he was transferred to Mengo hospital where we were finally able to complete his care.

After all was said and done we had reviewed approximately 50 patients and operated on 8. The pathology was relentless. The health care provision in Uganda is inconsistent at best. The system is plagued by different problems than we experience in North America, yet the outcome is surprisingly the same. For instance, trying to obtain a CT scan in a timely fashion; In Uganda the patients can’t afford to pay for it, in North America the insurance companies frequently deny coverage, the ultimate result is that if some one does not take responsibility or is accountable health care is delayed or denied.

In Uganda the economics of health care are also severely skewed. A thoracolumbar CT scan cost the equivalent of $120 US which included the radiologist’s interpretation and the technical costs. Yet with the low relative cost of a CT scan the hospital still has no linens to provide to the patient or to drape a sterile field during surgery.

I was troubled to realize that what we take for granted or consider disposable in our high tech, high cost health care environment, is absolutely priceless in Uganda. The simplest things like tape, gauze bandages, sterile dressings, OR linens are all considered a limited resource and potentially re-usable in Uganda.

Intra-operative sterility appeared to me to be an enigma. The staff were absolutely adamant that street shoes be removed for dedicated theatre shoes, yet there was only a limited supply of disinfectant and frequently the instrument packs which were sterilized came to the operative field contaminated or wet. The most fascinating aspect of operating in Uganda was again just to emphasize the point, the recycling of equipment, supplies, and even intra-operative sponges for multiple surgeries.

Towards the end of our visit, we met with Dr. Beyeza, Chief of Orthopaedics at Mulago, and Angela Balaba. Ms. Balaba is an impressive and motivated individual who is a wheelchair dependant paraplegic as a result of a motor vehicle accident. In response to her struggles with her injury, treatment and rehabilitation, she founded the Ugandan Spinal Injuries Association. As a result of their combined interests, the two share a vision to create a comprehensive spinal program with a dedicated ward and theatres. After much discussion it was clear to me that their goals are admirable, however their focus was unrealistic. It is clear they should not expend their efforts accessing or purchasing "pedicle screw" systems. What is most needed is expertise and appropriate first response care for the spinal injured patient. The efforts expended should be on teaching the first responders to protect the spine and training the house staff and nurses on appropriate work up, traction, prevention of bed sores, pulmonary care and nutritional care for these unfortunate patients.

One of the most troubling circumstances I had witnessed in Uganda was the lack of expertise in the maintenance or repair of equipment. Some of this is due to economic issues, where they are simply unable to afford the manpower, and some was just lack of training. As an example, at the Mbarara hospital a well meaning donation of a CT scanner has been sitting idle in a shed, still unassembled for the past 5 years. Apparently one piece of hardware or software is missing, no one seems to know what, and the administration can not afford to get the manufacturer to send the expertise to sort out the problem. The result is a well meaning, yet wasted effort. Other examples exist of ward equipment, operating room equipment and even fluoroscopic units, that with just minimal maintenance could be very functional.

I found the Ugandan health care professionals a compassionate, caring and for the most part dedicated group. What is lacking is basic infrastructure, i.e. appropriate trauma triage, adequate ward conditions, appropriate equipment maintenance, etc. At this stage of development of their health care infrastructure, I would not recommend the acquisition of more costly equipment. What is absolutely essential is education and training.

Somewhere, over time, I either consciously or sub-consciously, developed the misconception that on this trip, I would encounter a less than compassionate and caring society. This was far from the truth. In Uganda I found the patients and families to be respectful, caring and devoted to each other. They are accepting of their misfortune and do not blame anyone else. They are remarkably resilient and resourceful. Despite what would seem a significant disability they persevere and survive. The reality of it all is that they simply do not express their emotions as openly and are far more accepting of their predicaments.

The Spine Surgery Camp was a tremendous experience. Much of the pathology I saw was preventable or at the least the ramifications could be minimized with early and appropriate basic treatment. I anticipate that in the future we will be able to expand this program to a comprehensive spine initiative involving teaching, research and clinical care. I will regard this experience as a highlight of my career and do look forward to many more visits to Uganda.

Respectfully Submitted
Isador H Lieberman MD MBA FRCSC