Gisenyi/Goma: It was incredible. Such a wet, beautiful place on a huge lake (Lake Kivu) looking accross the water at congo and the setting sun. The drive was a mixture of good and crap roads - the good were being built by a German company called Strabag, (and they drive really really crazy), the bad being ripped apart by taxis and trucks driving a million miles an hour through the potholes. I reckon you could scuba dive some of them.... We almost got killed at one point, ironically it was by a Strabag employee driving on the wrong side of the road around a blind corner on a mountain road at a ridiculous speed!

The first couple of nights we stayed at a town called Kinigi, right up in the mountains next to the gorillas. After arriving Thursday night, we woke up early on Friday morning and climbed Mt Bisoki, a 3700m high volcano with a crater lake on top. It is the highest mountain I have ever climbed, and i found the altitude a challenge. It was hard to keep the oxygen replenished at the top but I found the going good if I went slow. It was very muddy, slipping and sliding so much it was like skiing at times!!! We got up in 2hrs, which is apparently a really good time, passing through alpine meadows, forests and large areas of herbs and so on.

The absolute amazing thing about Mt Bisoke was that we saw a silverback gorilla male (at least 20y.old) on the trail. Apparently that is very very rare to see one out and about on his own - maybe he had decided he was never going to be the top so he set off on his own to start a new group. So we were lucky. They are big creatures - the ground was thumping as he ran past, probably about 180kg. Lucky we had 3 armed guards, plus the porter, plus the guide!! But in fact, it is the buffulo that are the most dangerous. Also, luckily we didn't meet any geurillas.... Dian Fossey had her camp very near to where we stopped for a breather, it was amazing to see the area where she lived and worked. "Gorillas in the mist" was filmed nearby - I'm sure at one point they were walking on the same track we were (I saw the film after going there!!)

So we went to bed with aching legs, covered in mud and without a hot shower. The next day we woke to a light drizzle - the day for the gorillas!! We ate brecky and arrived at the ORTPN meeting place at 7am where I drank my first cup of coffee in weeks... ahhhh sweet african nectar! It went down well. We were soo lucky - the ORTPN have about 14 or 15 groups of gorillas, 7 of which are visited, and 7 are studied. We wanted to go to Susa, the biggest group of wild mountain gorillas in the world - but we were told we couldnt. With 41 gorillas, including 3 or 4 silverbacks, a dozon or more females and a stack of immature males and females and babies, it was the ultimate chance. We were pretty down when we heard the news, but we kept asking and then suddenly a guide grabbed us and said "Susa? Lets go!!" They only let 7 ppl visit per group, for 1hr per day. So off we set, with 4 crazy Dutch doctors (2 plastic surgeons, 2 anaesthetists in Rwanda to do 50 or 60 cleft palates). It was about a 45 minute drive to where we started walking. When we got there, the guide told us the walk could be up to 6 hours, depending on where the group was located. We shouldered our packs and hit the trail. Again it was muddy on the flanks of Mr Karisimbe, the highest peak in Rwanda, but there were more stones on the western side than in Bisoke, so the mud wasn't as thick. But, the undergrowth was something else!! we waded through the thick herbage, into bamboo forests, all the time getting wetter and wetter as the famous mist rolled in... and then there they were!! the trackers!! that meant we had found the gorillas. I glanced at my watch, it had only taken about an hour - what luck.. we ditched our bags and our sticks (no food or threatening objets), had a quick discussion about how to behave, and then we scrambled through the undergrowth in single file, clambering through the fleshy plants. Then suddenly, we found ourselves face to face with a subdominant male only a meter or two away, sitting in a pile of branches he had flattened, chewing on a branch. For a 180kg individual, he has to eat 30-40kg of leaves a day -they are vegetarian. awesome. We continued a little further and found ourselves in amongst the dominant silverback and his harem of wives with children playing around at their feet. We stayed nearby for the hour, watching these giant creatures at rest, the guards imitating the gorilla speak - low grunts of contentment to say that all was ok. It was an amazing experience, unlike any I have every had before. I can't really put it into words, they are so huge, so much like a human it is a kind of uncanny experience. just to watch the kids play... so much like us.

So then on saturday after the gorillas we busted out of kinigi and headed up the road to Gisenyi next to Goma. When I say next to, I mean right next to. The border is in town - we went to see it just to say we had been there. But we didn't stay in town, we went to a place called Paradis, and it was paradise. What a spot. wow. Beautiful scenery looking out over the lake to the congo where the sun was setting. we were far enough away that we couldn't hear the gunfire, we might as well have been on another planet. So while we had a Mutzig (rwandan beer), there were 250 000 refugees massing on the border trying to get away from the rebels. Africa is a continent of absolute contrast. It was hard to believe that one of the most peaceful places i have been was so close to so much misery and anarchy. Anyhow, the border was closed so we couldn't get across to Goma. We met some Australians there that Mark knows, so we chatted and had a few drinks. Unfortunately, Andrew locked the keys in the car, and we had to spend 3hrs trying to break in. We eventually abandoned finnesse and went for brute force - we just bent the door open and a very thin rwandan bellboy bunged his hand in the hole and opened the door!! A quick bend back into place, and bob's your uncle (except for the slight leak in heavy rain...). Lets just say the beers were well deserved!!

So then the next day (Sunday) we drove back with the two Aussies. Things were getting hot in Goma, but we didn't know at the time. I'm glad we left when we did, but also glad that we went. Interesting experience.

Then, we stopped on the way back at a couple of little markets and Di (the Aussie nurse) taught us a thing or two about aggressive bargaining. I will never be ripped off again!! hehehehe... She is a nurse at King Faycal, a rwandan private hospital in Kigali.

So monday, we started at the hospital. we were met by the congolese Dr Polepole. An awesome teacher, a great obstetrician and a talented surgeon. he is deputy director of the hospital. we went on rounds with him, and then I saw my first ever live birth. I have learnt how to track a pregnancy and what sort of problems can arise. We then scrubbed in and saw the repair of a patent tunica vaginalis with an accompanying hydrocoele repaired by Dr Polepole and Dr Yuma as assistant. He is very good. they went into the inguinal canal from a suprainguinal approach, found the genitofemoral nerve, ductus deferens and the patent vaginalis behind it, then ablated it by tying it off and cutting it. they then sucked out the fluid from the scrotum - finished!! very neat, excellent work. we also caugh tthe tail end of a caeser after lunch, as they were closing. What a first day!

Second day was a bit harder. Dr Polepole went to Kigali for a meeting, so we were with Dr Ishmael. We arrived and a women was in labour who had been in labour all night, but the nurses hadn't informed the doctor of teh foetal distress. Bad news. At about 930 the doctors decided to caesar her because the baby was in such distress. But, by the time they got her into theatre, Yuma did a final listen with the foetoscope and the baby was dead. So instead of doing a ceasarien they gave her ergometrine and she gave birth to a still-born child. I saw her a few days later, she was distraught at having lost her child. Then, we followed Yuma into a repair of a hydrocoele in an adult prisoner. Prisoners have a HIV rate approaching 80%, so there wer extra precautions in place. The man was so frightened, he was very very jumpy. The doctors said all the prisoners were like this - they have a particularly shit life.

As he was serving a life sentence, the guy was may have been one of teh people involved in the genocide and tried under Gucaca (a local law system used to give payback to the genocidaires). His skin was very thick, presumably from his hard life. So now I have seen the repair of both communicative and inflammatory hydroceole. How they fixed the inflammatory one was quite ingenious - you dissect through the scrotum until get the tunica vaginalis and you slice it open to release the fluid. once released, you extend the breach until you can evert the testicle. You then get the air out and sew the vaginalis shut. Sounds wierd, but that puts the serous surface of the tunica vaginalis on the OUTSIDE - so any fluid is absorbed by the dartos muscle!! ingenious. you then close the layers surrounding the testicle. Fantastic operation. It does nothing to cure the cause of the inflammation/fluid build up, but it does remove the symptoms. Filiariasis is a common cause here - in another 5 years the prisoner may have elephantitis.

We then say a little boy who had been smashed in a car accident. The mother had died, and they didn't know who he was. When the relatives arrived, they had absolutely no money. They could not afford the 6000RF to give him antibiotics and anticonvulsants for his head injury (cerebral oedema, skull fracture, raised ICP, focal signs of decortication). He was very ill. So I gave them the money - about $15AU. I saw him again today - he is not getting much better. I think he will die either tonight or tomorrow - there is nothing more we can do for him here - they don't even have mannitol - and the family definately cannot afford to send him to Butare where there is a teaching hospital. So. Thats why it wasn't a good day. We then had the amazing opportunity to see a c-section of breach birth. The baby already had a leg out when the woman came in to hospital. Straight to the OR. She couldn't be anaesthetised because the baby was alreay in too much stress, so they just gave her a quick local and made the incision. The doctors needed to move fast BUT the intestines where IN FRONT of the uterus. they had to push about 4 loops of bowel that herniated out of the midline incision back into the cavity and wedge them there with padding. I won't say what they use for padding... but it is rudimentary. so that took time. the mother was in some pain, so they gave her diazepam. then the tricky bit. Dr Yuma incised the uterus low, and grabbed the leg still inside, and tried to get the bum oriented around while the other surgeon assisting (Dr Ishmael) pushed the other leg back inside. they managed to get both teh legs out, and then they had to deliver the head. The baby popped out after some manipulation, and they passed it to the nurse and turned their attention to the mother, who was given a big bolus of ketamine straight away to knock her out. During the proceedure the uterus tore and it took them another 35 mins or there abouts to control the bleeding. Luckily, the baby was ok. I have never seen soo much blood, all over the floor, everywhere. With my lack of experience I thought she was going to die for sure, but I kept quiet as the doctors remained calm and continued to work hard. The worst part was that there was a posterolateral tear on the left side of the uterus so that even after suturing the main tear kept on bleeding. I monitored her for shock, but it remained on the curve of compensated shock - pulse 120, breath rate 40, veins still palpable - no venous collapse. Phew. What a scary experience. I must have been showing my concern, at one point Yuma turned to me and said with typical doctor panache "Blood is red, you know??" Yes I did know, but I didn't UNDERSTAND. Massive blood loss is a scary thing, but the healthy person has an amazing ability to compensate. It turns into a mass of goooey goop that schlooops onto the floor sticks things together with the most incredible hue, eventually dulling off to a dirty smudged brown on the gloves and tools of the trade. A valuable experience. After closing, the doctors let out with a bit of nervous banter, joking about the case. It had been a close call, and they knew that having both mother and baby alive at that stage was more than they had secretely hoped for. C-sectioning a well progressed breach birth is a dangerous business, however both may have died without thier intervention. Needless to say, I was amazed to see the mother conscious and weakly smiling today in ICU when we went to visit the little boy (ICU being 6 beds with no equipment that really sick people go to after operations).

The doctors here are great, all under 35, verygood at what they do with almost no equipment. Like i said, no mannitol, to ability to pay $15 for drugs, no basic equipments. they make do with what they can. It has been an educational experience for me - somehow I don't think a rural australian hospital will be radically different from Nyanza - at least here they have X-ray and a lab!!!

So today we observed another birth, and Andrew restitched the episeotomy under the direction of Dr Polepole back from Kigali. I watched them animate the newborn, so to speak by aspirating the amniotic fluid from the mouth and nose and rubbing it, and then I did the APGAR scoring and the initial examination. After a slow start, he was a happy little chappy. We then went back and checked up on the injured little boy from the car crash - he had had his drugs but was having convulsions, still decorticate. I am very scared for him... life has a definite price here, and it isn't very much at all. We went on ward round with Dr Polepole again, what a champ! he is teaching us a lot about maternity. Andrew and I then went and did a circumcision each on 22yo guys. Quite a bizzare experience, but there we were. I did mine first - I had never seen a circumcision before so I didn't know what was going to happen - i just had to do it as Dr Yuma told me - quite a novel experience. Andrew had the benefit of having learn't by observation, and his ended up neater. But both were considered excellent by Dr Yuma, and he said we have now started earning our keep because we made the hospital about $30 today!! hehehehe.... So that was amazing, my first minor ops! and it was a total success. And that is all i have to tell.