Volcanoes and exploding lakes

Trip Start Feb 17, 2011
Trip End Apr 01, 2011

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Flag of Rwanda  ,
Tuesday, March 22, 2011

A friend of Jessica's and mine arrived this week to accompany us to Ruhengeri to take the opportunity to hike up into the mountains and watch the gorillas. 
We drove from Kigali and spent a night at the shore of Lake Kivu before I started work at the district hospital and they went up to see the gorillas.  This is one of the largest lakes in Africa and is one of the deepest lakes in the world, reaching about 1,500 feet.  It's an interesting area because of the geothermal activity, with a looming volcano just above the populus which continues to have a lava lake and gas rising from the caldera.  There is a striking change in the color of the soil and rock as you approach this part of the country because the ubiquitous red rock and roads elsewhere in the country give way to black volcanic rock and pumice.  The lake has a significant buildup of methane gas, which is currently being extracted by several on-water stations.  The lake is one of three "exploding lakes" in the world.  The accumulation of CO2 and methane within the lake has sporadically caused catastrophic eruptions of the lake in the distant past.  It is thought that a future explosion could potentially suffocate inhabitants in the valley of the lake, as well as pose a risk of a tsunami. 
The methane and CO2 extraction at this point is merely experimental, but it could potentially allow Rwanda to increase energy production by 20-fold and become a significant source of income through exportation of energy.
The lake is bordered by the Democratic Republic of the Congo and Rwanda.  We stayed a stone's throw from the Congolese border and watched UN planes continually fly in and out of the neighboring airport in Goma.  Very little is known about what is happening in the heart of the Congo given the continued political instability in the country.  DRC has emerged from one of the deadliest wars, with an estimated 5.5 million people killed in the last decade of fighting.  Eastern DRC, in particular,  continues to be plagued by conflict and violence.

Ruhengeri District HospitalHospital Grounds

Ruhengeri District Hospital is one of the largest district hospitals in the country, serving approximately 400,000 people, and containing approx. 450 beds.  Despite this, there are only 4 general practitioner physicians, and no surgeons.  Therefore, the general practitioners are expected to funciton as general surgeons.  They were fortunate to have a Cuban general surgeon who recently left after a two year appointment here.  This surgeon trained the current physicians to manage general surgical problems.  However, they operate on a broader spectrum of surgical disease than most general surgeons in the United States.  They perform laparotomies daily for typhoid perforations, appendicitis, incarcerated hernias, as well as OB-GYN emergencies, thyroidectomies, thoracic surgery, orthopaedic surgery, and of course, trauma.

My first day at the hospital began at 7am with hospital wide morning report (in French).  Afterwards, the G.P.s had me accompany them on surgical ward rounds.  This involved seeing approximatly 100 patients over about 2 hours.  During rounds, we made a list of 35 patients who are needing to be scheduled for surgery.  The smell on the wards is a bit overpowering at times, as there is only 1 nurse for every 60 patients or so, and so it is understandable that wounds are not being managed adequately.  Dressings on large pressure ulcers or abscesses are not changed for several days, and you can imagine the rest...

After rounds, we sat down to make an operative schedule for the week, with a capacity of about 6 major operative procedures per day with the three OR's running, though this is rarely feasible given the lack of staff.  One of the G.P.'s and I  then operated on a 9 year old girl who had come in overnight with generalized peritonitis.  She ended up having ileal perforation, presumably from thyphoid enteritis (caused by Salmonella typhii).    New admissions were admitted and added on the OR schedule, bumping the cases that we scheduled in the morning.  Today, we got through some of our scheduled cases, though half of them were cancelled because one of the anesthesiologists couldn't come to work... 

Bottom line - they need about 4 more general surgeons to help the three or four G.P.'s, a few orthopaedic surgeons, and about 30 more nurses to just to tread water.  I'm not even considering what's happening on the internal medicine or pediatric wards.

Generally, patients are not transferred to Kigali  because there are either no available beds, or patients refuse because they cannot afford the transfer nor can their families afford to come with them to feed them, find room and board for themselves, and leave their livlihoods for prolonged periods.  GoiterTherefore, the G.P.'s here are faced with tackling challenging surgical problems like removing this woman's large goiter which may have attendent risks of airway compromise, or complicated orthopaedic injuries that require fixation that is frequently not available at this hospital.  Thus, some patients must lie in beds for weeks to months at a time while in traction.

Next installment... Woman gets tackled by silverback gorilla, and walks away with no more than a 'big' hand print on her back...
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