Greetings from Bambari

Please forgive excessive medical jargon and stories.  If you are not medical, feel free but not obliged to move on.      Well nourished previously healthy infant is transferred from an outlying health post with persistent seizures, fever, encephalopathy despite one week artesunate and ceftriaxone.  On arrival here he is started on the protocol - artesunate and ceftriaxone. (and diazepam).  In absence of skin lesions next step in protocol is add gentamicin.  I order, throw in levetiracetam.  I find out, we have gram and giemsa staining in the lab (for now, anyway).  Kid deserves LP, though no micro.  Maybe lympho predominant will buy TB tx, or eos I can do albendazole for Strongyloides (I saw CNS S. stercoralis in Boston once upon a time).  No India Ink.  LP uncomplicated, CSF clear, glucometer cannot read.  Gram stain neg, 10 reds (no one to champagne me anyway) WBC 5 (no diff.)  So not much help.  One day (well 8d) into ceftriaxone w 1 day genta/Keppra seems to be defervescing, a litt

 Ok, the tachycardia I can deal with.  Our transfusion threshold is 4, or 6 if you are "intolerant."  Hypoglycemia, sure.  Coma, seizures, fine.  But the bleeding!  I want to know - DIC?  Fulminant liver failure?  Simple malaria thrombocytopenia?  Viral hemorrhagic fever?  No one seems to get petechiae, or maybe I'm missing it.  Not that this differential helps me treat in any way.  I have vitamin K, I have whole blood.  I have antimalarials, I have antibacterials.  I can run a bedside hemoglobin.  I can pretend I'm doing coags with a dry glass vial waiting for clot to form (there are actually published norms for that).  I've run into a string of upper GI bleeds from what?  (Ok, one of them was a battery acid ingestion.)      Diagnosis is elusive.  Miraculously, kids often survive.  Serious brain damage on the other side is sadly common.  A nurse asks me, what does enlarged liver or spleen mean?  My reply doesn't seem to help: just about everything one runs in

 A fortuitous concordance between traditional French bureaucratic style and Central African culture produces an occasionally delightful opportunity for longwinded flowery speech where least expected.  Morning greetings may go on for quite some time through an assortment of polite inquiries into each other's previous night's sleep quality, the health of relatives, and so on.  Meetings may be punctuated by gracious thanks on the part of each speaker for the kind attention of the listeners and the generous sharing of the floor on the part of the meeting leader.  In such meetings ambitious plans may be shared to general acclaim.  And, when nothing happens by the next meeting, we get to do it all again!      My predecessor launched multiple worthy initiatives, but there are not fully evident less than a month after her departure.  The patients, the hospital, the prefecture (province), the health system, the country - a bottomless pit of need.  There is generally a gratifying alignme

 I saw my first Russians in town last weekend.  Just three of them, walking down the street in plain clothes, knit masks pulled up to just below their eyes (too hot for balaklava?) , automatic weapons.  We passed wordlessly.  I did not take a picture.      Here is today's pediatric intensive care team, group photo.  And, bonus - we have four empty beds!  I may take some boarders from the malnutrition ward tomorrow, which has kids doubled up on the beds.  And, those kids are crazy fragile so I wouldn't mind them.      One of my persistent fever/coma kids woke up enough today, hospital day 9, to swallow a quarter teaspoon of mushy cereal!  Everyone in the ward applauded.  Later, she wouldn't stop crying.  But still, not a coma!  Earlier in her stay I discussed withdrawing care when she required repeated bagging for recurrent apneas (bag and mask breaths because she kept stopping breathing) - Mom said keep going - then apneas stopped when I just tried a Keppra load for non-con

     My direct supervisor, a Colombian-Canadian, will have 1 month vacation.  He passes me the "Medical Activities Manager" cell phone, laptop, emergency (Ex-pat residence) medical kit.  I am unsure what this interim position entails, and how I do it.  Fun! (not)      On the plus side, the rag rug project has begun!          שֶׁהֶחֱיָנוּ וְקִיְּמָנוּ וְהִגִּיעָנוּ לַזְּמַן הַזֶּה      Translations:  I have applied Sango titles to each post, hopefully apt, for my own entertainment.  I list them here with translation, and will translate the future titles when posting. Mbi ga awe - I have arrived. Pendere kodoro ti Bambari - Beautiful town of Bambari. Kangoya? Awara awe - Palm wine?  Got it! Dounia ayeke ngangu - Life is hard. Na nguinza, wala sengue? - For sale, or free? Amolengue akwi kirikiri - Kids die like crazy. Bongo ti sala na nyen? And, Mbi ga kota zo (kete). - Fabric, to do what? And, I become a bigshot (a little one).

 Day starts with a bang.  Two children in status epilepticus, one unconsolably screaming toddler seems encephalomeningitic, and my favorite ex-preemie (26 week twin) getting CPR, two round of epi.  She has fought her way to the age of 7 weeks, three of which were spent at home.  She has not quit through 2 weeks of unremitting fevers, tachypnea and tachycardia, but I have run out of treatment options.  She survives the resuscitation, then recurrent hypoventilation/apneas.  We bag her back 2 more times while discussing likely outcome, with help from the "mental health" team.  I and the nurses (including initial stay in the NICU) have had trouble connecting with this teen mom of few words, although she does not object when we stop bagging during arrest # 4.  I learn that labor was triggered by a fall.  Healthy toddler sib at home.  I didn't know.      Eventually apneic, starts to brady down.  Mother declares that the patient is already dead, and she wants to leave with her. 

 The hospital is a hybrid - pediatrics (PICU, NICU, gen peds and peds ED) and surgery "supported" by my NGO, OB non-surgical run by another NGO (although C-sections being surgery are with us), Medicine and adult ED straight national Ministry of Health run, and then the whole hospital is run by national Ministry of Health staff "supported" by my NGO.  My NGO also "supports" on-site and distant ambulatory clinics and specialty sexual violence survivor support program.  Rehab (inpatient/outpatient) is by yet another NGO.  Every department has staff who are full-on NGO, full-on Ministry of Health, and hybrid employees.  There are parallel management structures.  Everyone but me seems to understand who is in charge of what.  One rule is clear - if my NGO "supports" a particular unit, all care there is free.  In other parts of the hospital, including the same service ordered on a different ward, fees may apply.      Sign in Sango says, "You pay no

I was planning to write about Sango, a language I do love because of it's large capacity for eloquence through metaphoric deployment of a very limited vocabulary, simple grammar, and its history as a language by and for everyone, and not one ethnic group in particular, in the country - a collective ongoing creative endeavor of the Central African people.  But too many kids die today in the ICU.      Late last night death suspect fulminant hepatitis (skin too yellow, liver too big and tender, hypoglycemia too prolonged, for just another malaria).  This afternoon two year old probable bacterial sepsis.  We guessed wrong on the antibiotics, or maybe we didn't have any for who knows how resistant the bugs are here (no micro), or maybe it was Rickettsia or Borrelia (no spots, no rash, no louse, no tick, but who knows?)  Mom was stoic as she gathered up the boy.  She left grilled corn for the staff.      Who will not make it to tomorrow?  Should I get Local Style and start going &quo

 I have learned a new unit of measure - the "Evian."  It is a plastic bottle previously containing Evian water, now used apparently for the measure and sale of palm wine (kangoya in Sango).        An ex-pat housemate and I order up a jeep transport to the center of town.  We swing by the "Evian" seller to buy the requisite empties - I must leave an IOU because small change is in terribly short supply.  The open-air bar/kangoya stand 100 yards further fills our empties at 85 cent (US) each.  While we wait in the car for our driver, children bearing kola nut (goro) offer wares - but no small change!  Maybe next time - I decline the free sample offer.  A gentleman who has perhaps consumed one Evian too many of kangoya effusively offers thanks for our service to his community.  Driver returned with our two Evians of kangoya, we go back to the ex-pat house.  Will the fizzy sweet/sour and lightly alcoholic taste be as I remember?  Can anyone step in the same river twice?

 HRUB - Hopital Regional Universitaire de Bambari - has five pediatric units: NICU, PICU, Malnutrition, Gen Peds and "Triage" (mostly ED aspiring to be Obs unit.)  Mortality is crazy high by US standards, but given constraints, child death is simultaneously devastatingly frequent and miraculously held at bay.  I have been installed in PICU as a "specialist" since I am residency trained, which outside of the capital is a rarity.  The hospital has a reputation in town of very high quality - the best, ever!  Thanks to my sponsoring NGO, the "essential medicine" formulary is generally, mostly, in stock.  Most important,  patients receive care - in pediatrics, and surgery wards - free of charge which is not the case in internal medicine, adult ED and maternity wards.      I am a subject of amazement and curiosity, given my relative fluency in Sango (from distant 3 years in country as a Peace Corps volunteer).  I was briefly in this town for training then elsewh

 I arrive in Bangui after 30 years away.  Central African Republic's international airport is much more organized than back in the day.  The city seen from the airport transport van looks like the bustling capital of memory.  But curfew will start soon.  Electricity will cease as well.  Safety on the streets is not assured, and walks to the market or the restaurant-shacks along the Oubangui river are not permitted. The warm welcome, generosity and good humor of my Central African hosts is as remembered.  The mangbele (chikouang in Congo), unobtainable even in African grocery stores in the US, and the best 15 cent shoeshine on the planet are nice.  My medical non-governmental organization's orientation along with handover from my pediatrician predecessor will allow for 4 days in Bangui and ample time to resuscitate my Sango vocabulary.