Day 6 - 10 | Start of week 2

I’m not going to dwell too much on the medical side this week as I’m sure you’d much rather read about gorillas instead of the clinical cases I found interesting. However, I think there are some important points to highlight, so here’s a brief recap of what happened at Panzi since last Saturday (11/01/2020).

The previous week ended off with a long 26-hour call. A rather calm night but only due to torrential rains that lasted the entire call and made most roads leading to the clinic completely inaccessible. My night was spent monitoring patients and tutoring third year students. The university’s medical faculty is reasonably large with most classes exceeding 150 individuals. On the other hand, Panzi only has 450 beds and is the sole hospital tasked with training all these students. This results in medical students only being exposed to 18 months of dedicated clinical blocks during their seven years of training. This stands in stark contrast to the three full years of clinical exposure we receive at UCT. Nonetheless, these students make remarkable compromises and tackle their studies with incomparable dedication and perseverance.

I was stunned to find third year students arriving at the hospital for their “travaux pratique” (practical work) at midnight on a Saturday evening. Apparently, every day from midnight onwards, a group of 20 third-years are tasked with taking histories and examining patients. The student interns on call then spend the quiet hours of the morning tutoring and going through student presentations in between admissions in the emergency room. I thus found myself tutoring eager students until the crack of dawn. I went home on Sunday morning in awe of everyone here and with newfound motivation to tackle my final year.

I was back in clinic on Monday morning for a short three day week in view of much needed public holidays coming up on Thursday and Friday. On wednesday morning, Dr Marie and I completed the 20-hour haematology lecture series she started last week. After a few photos, I was back at Panzi for another gruesome night call.

I describe a distressing clinical case below and pressing problem experienced here at Panzi, skip to the following section if you're not particularly interested in the medical aspects. I've tried to simplify it as best as possible for those not in the medical field.

During the afternoon we admit a patient with what I suspect is a stage 4 hodgkin’s lymphoma. The young gentleman is suffering from a severe anaemia (Hb 3 g/dl) and generalised lymphadenopathy further restricting his movement and breathing (hilar nodes). Early into the evening, following his x-rays and an inguinal biopsy, he is severely short of breath and Dr Marie suggests I transfuse him before she goes home. One thing to note here is that we have zero access to chemotherapeutic drugs or irradiation and that blood transfusions are an extremely risky business in Bukavu.

For those not familiar with the transfusion process, this requires some basic background information:

• Blood typing is the first step. This test finds out whether you have blood type A, AB, B, or O. Your blood is also tested to find out whether your Rhesus type is negative or positive. It’s important to know your blood type in order to select a donor’s blood that is compatible before doing what we call a crossmatch.
• An intermediate step between blood typing and crossmatching is called a recipient antibody screen. This test checks for unexpected antibodies in your blood and can sometimes delay the selection of compatible donor blood.
• Lastly, crossmatching is a way to test your blood against a donor’s blood to ensure they are fully compatible. Crossmatching usually takes 45 minutes to an hour. It’s essentially a trial transfusion done in test tubes to see exactly how your blood will react with potential donor blood.

 

 

With those fundamental basics in mind, I head to the blood bank with a sample of my patient’s blood (the recipient). Hiis folder noted that he was AB+, but this is something I’m always weary about as mistakes can easily be made. I nonchalantly request to get one unit of iso-grouped and crossmatched packed red cells. The lab technician chuckles and explains that they do not have packed red cells at Panzi(only whole blood), no crossmatch facilities and that he is not going to waste money retyping my recipient’s blood if his folder already states that he is AB+. I tentatively return to my patient with one unit of AB+ whole blood and re-assess whether he really needs this unit of blood. Unfortunately, he is already fatigued due to his tachypnoea and unable to stand up from his bed. I reluctantly ask one of the nurses to show me how they start their transfusions here. Without a formal crossmatching protocol, the only safety screening method they have here is to draw a few drops of the recipient’s blood and mix it with it with a sample of the donor’s unit in a syringe while observing for any sign of agglutination. After a minute or two, the nurse deems it safe and begins the transfusion.

I watch my patient like a hawk due to the treacherous risks and by 18h00, 30 minutes into the transfusion, his temperature suddenly starts spiking at 39.5°C (coming from 37.0 °C) and he becomes agitated with acute palpitations, severe flank pain and worsening shortness of breath. I find myself cursing under my breath, all alone in the emergency room with a probable acute haemolytic transfusion reaction. I immediately stop the transfusion, put up an alternate intravenous site to start hyper-hydrating my patient and administer corticosteroids and a diuretic. His urine soon turns coca-cola brown/red (haemoglobinuria) due to the intravascular haemolysis and I’m pretty certain of the diagnosis despite being unable to do any further blood tests due to cost and lab limitations.

He refuses oxygen due to traditional beliefs and seems to be hanging on for dear life during the next few hours. I find myself searching up treatment protocols and contacting Dr Marie for some practical advice. I spend a sleepless Wednesday night monitoring him as he stabilises throughout my call. I hand over to the relay team on Thursday morning, beyond relieved I did not kill my first patient! It’s not all joy though, as such reactions are frequent here, having killed at least two patients in the last week alone. I head home exhausted after my eleventh consecutive day at the hospital in need of some much needed rest.

End of clinical case.

Day 11 | Thursday 16/01

I grab a quick breakfast at Coco lodge following my call and jump straight into bed. A mere 10 minutes later, I find Dr Marie knocking on my door with a tempting proposition. She just came across the brother of a patient she treated in Belgium last year, whom is offering to take us on a local tour of Bukavu. I drowsily accept knowing such an opportunity doesn’t come twice and change back into some decent clothes. We are also joined by the only nephrologist in the province and set off driving to our first stop: Clinique Saint Luc de Bukavu (St Luc’s clinic of Bukavu). This is a brand new 70-bed private hospital commissioned by a Congolese entrepreneur supposedly linked politically to one of the diamond mines in the region. We get a guided tour of the facilities that opened their doors on the first of January. Everything is brand spanking new, still wrapped in protective delivery packaging and rivals our private clinics back home in South Africa. Having spent two weeks at Panzi, Dr Marie and I walk dumbfounded and juxtaposed through the hospital wondering how such a facility came to exist in this region.

Upon further exploration, we are a bit confused on how this hospital is going to run: the facilities are astounding but there is a total lack of staff and specialists to run all these specialised services, there are some massive design flaws (hallways too narrow to accommodate patient beds, a risky open ventilation system, seven steep floors with a single ramp interconnecting them), machines from every possible international company without a maintenance team or plan and a population predominantly unable to afford the exorbitant hospital rates.

A lack of organisation, planning and maintenance seems to be a recurring problem here in Congo. One which we’ve seen first hand at Panzi where many specialised facilities and technologies are available but have become damaged or decommissioned due to lack of maintenance/breakage. I hate to sound pessimistic but I hope Clinique Saint Luc can overcome these problems and continue running for a number of years.

After the hospital tour and a drive through bukavu, we decide to lunch at Hôtel Panorama which borders the lake with splendid views of Rwanda on the opposite shore. Here we spend a few hours discussing how to improve the various medical facilities here in south Kivu. Dr Marie has taken the initiative to create a report for Dr Mukwege and his team on the possible advancements in the haematology department. We all agree that the blood bank and transfusion services necessitate urgent attention in order to prevent further avoidable and tragic deaths. The nephrologist accompanying us offers us some crucial insights into the problems and challenges he faces running the only dialysis center in the region. We end the afternoon with another guided visit. This time it’s at l’Hôpital Provincial Général de Référence de Bukavu (General Provincial Reference Hospital of Bukavu - HPGRB), where the nephrologist works at.

I get back to Coco lodge at 18h00, eager to get some sleep but once again get a phone call with another interesting proposition. Bill, the paramedic I met on my flight from Kamembe to Kigali who works for the International Committee of the Red Cross (ICRC), invites me to come and have dinner with the local ICRC team at one of their safehouses down the street. I obviously can’t say no and he picks me up in one of their jeeps.

We spend the evening enjoying Indian takeaways and exchanging stories from all over the globe. The team consists of various workers from Belgium, France, Columbia, UK, Switzerland and Kenya. They are tasked with a number of humanitarian, peacekeeping and educational programs across local prisons, hospitals and mining conflict areas. Hopefully I’ll get to join them on one of their missions during my stay here! I get home at 01h00, with a meagre four hours of sleep before heading to the gorillas on Friday morning.

Day 12 | Friday 17/01: A lifelong dream come true

I’ve waited many many years for this day to come! It’s been a lifelong dream of mine to visit gorillas in the wild for as long as I can remember. The excitement is palpable and the 05h00 wake-up doesn’t even feel like a chore for once. Dr Marie and I arranged to go to the Kahuzi-Biéga National Park together and we set off in a dingy Toyota corolla on the two hour drive via muddy roads through small villages. We finally arrive at the misty park office and are greeted by the local guards.

We sit down and have some coffee to warm up while some of the trackers leave to find the whereabouts of some of the gorilla families. The park office sits at an altitude of 2200 metres and the chilling weather reminds me of Diane Fossey’s remarkable film “Gorillas in the mist”. We are quickly joined by another group of four Belgians, coincidently the manager of the luxurious Orchid hotel I was at last week, the daughter of the owner and two of their friends. The owner’s daughter grew up in in Bukavu and the manager has been a local for the past five years. This is their seventh visit to the park and they’ve known the guards and trackers for years. We’re therefore with the best possible company and Papa Lambert, the park’s head tracker, greets us fondly and takes us through the “briefing”.

There are three species of gorillas in the world, namely:

• The western lowland gorilla (Gorilla gorilla gorilla): Found to the west in the Central African Republic, Equatorial Guinea, Congo-Brazzaville and Cameroon.
• The mountain gorilla (Gorilla gorilla beringei): The last survivors found in the volcanic regions of the Virunga National Park in the DRC and the Bwindi forest National Park in Uganda.
• The eastern lowland gorilla (Gorilla gorilla graueri): The largest and most impressive subspecies with only 19 documented families remaining in the wild and an estimated total population of less than 3000. They are only found in the Kahuzi-Biéga and Maiko National Parks. This is the only place in the world where one can visit an habituated eastern lowland gorilla family in the world.

Papa Lambert concludes the safety briefing and we get confirmation via the comms that the trackers have located the rough whereabouts of an habituated family deep in the marshlands of the forest. It’s starting to pour down again as our group of six tourists and four trackers cramp into another trusty land cruiser in search of the gorillas! After a bumpy and slippery drive we reach the end of the muddy tracks and prepare to trek a few kilometres through the dense forest. The guards panga (machete) their way forward and I follow them while admiring the breathtaking greenery. I’ve never seen such luscious forests and my mind is dazzled by the interminable shades of green.

After walking downhill for an hour, we eventually clear the forest and enter a large open swamp. Out of nowhere, I suddenly hear the agitated chest beating of a large silverback and I know we must be getting close! We sink into knee-deep muddy water and make our way through the reeds in search of the alpha male silverback, named Bonne Année (Happy New Year), after his birth on the first of January 2003. I catch a glimpse of a dark shadow ahead and I can barely conceal my excitement while impatiently marching the last few metres. The reeds clear and before I know it I’m standing right next to Bonne Année and one of his females named Iragi. The next few minutes are still a blur, all I can remember is being mesmerized by the size of Bonne Année’s gigantic hands. He has a pair hands that could easily rip me apart if he wanted to but I somehow felt extremely comfortable and content to observe these majestic creatures in their natural habitat.

We spend the next few minutes admiring them as they feed and walk around the swamp seemingly undisturbed by our presence. I stand frozen as Bonne Année suddenly walks past me less than a metre away, secretly wishing he would reach out to touch me.

However, a troop of gorillas from a neighbouring family are grazing on the opposite side of the swamp and causing a lot of agitation. Bonne Année appears tense and suddenly lashes out in a series of violent chest beatings to mark his presence.

With such a captivating display, I fail to realise that Iragi is concealing an adorable 10-month-old baby nicknamed Moja. Only once he starts climbing onto his mother’s back do we get a full view of the park’s newest born. Our hearts instantly melt as he starts playing around. Unfortunately this doesn’t last long as Bonne Année retreats back into the forest. We scramble together and attempt to follow them as they nimbly make their way through all the thicket. We can barely keep up and eventually lose track of them.

We continue tracking their footprints and listening out for any hints of their presence. After a few hundred metres the forest once again opens up. We walk out into the swamp and are greeted by the rest of Bonne Année’s family! A total of eight gorillas peacefully feeding on reeds and leaves. The moment is magical and I grasp the opportunity to take a few more photos and videos, knowing this is a once in a lifetime opportunity that might never come again.

After spending well over an hour with this majestic family, it’s time to leave them in peace. One of the guards was kind enough to get one last picture of me with Bonne Année wandering off in background. We then start the long journey back home: a 90 minute uphill hike tracing back our footsteps to the jeep, followed by an hour of offroading to the park office where we say goodbye to all the guards and our new Belgian friends. I can barely manage to keep my eyes open as we climb into our little taxi on the way back to Bukavu.

We get back to Coco lodge in the late afternoon and I immediately set off on one last little mission for the day. During the week, I received some inside information from one the Egyptian MUNESCO (United Nations Organization Stabilization Mission in the Democratic Republic of the Congo) guards tasked with protecting Dr Mukwege. The UN base down the road from Coco lodge apparently has a little hidden gym for its soldiers. After a brief search, I find the right gate and knock on the metal door. Two armed guards open up and eye me out suspectively. I am in luck as these Egyptian guards come from Alexandria where I once lived for two years and we bond over the coincidental similarity. After a little convincing, I manage to get access to the gym for the rest of my stay here and enjoy a good workout! All in all, it was a pretty successful day.