Wali so - lo yeke fa molengue ti lo (That woman - she's going to kill her child)

Diagnoses come in bunches, wherever you are. We are enjoying pleural effusion week at Bambari Regional. Families (and doctors) are getting frustrated when two weeks roll by and the pus just keeps on coming. I am trying to negotiate special arrangements for refractory gram positive cocci and some weird filamentous things that may be fungus (one expert says, real vs contaminant) or nocardia/actinomyces (yes you said that, you know who you are), get some culture transport medium delivered to us and then send back to Bangui for culture, speciation and maybe even sensitivities.  She has a left supraclavicular node today, so that brings her score for TB likelihood (Keith Edward score, validated in India!) to treatment level despite AFB and  GenXpert gene probe neg - I've started on that.  Mom says she's HIV negative and hates needles so won't test- we're working on that, too.

     Another tiny baby, healthy well nourished, supercute three month old with left chest whiteout, chest tube also pouring out pus gram pos cocci, doing great decreasing drainage but afternoon of drain day 3 suddenly falls apart - gasping, unresponsive.  Breath sounds freaky continuous whine on affected side no matter how much I hand pump from the chest tube the bag just keeps filling with air - 1 liter, 2 liters, 3 liters, 4 - that's more than the volume of the whole kid!  I drop KY around the drain site to look for bubbles (leak at site, our surgeon's trick) - nothing.  I call surgeon to come in from home - he's like, we need a chest xray.  This is a big commitment, because we have to unhook the oxygen and sprint across the compound to the radiology room, then rush back.  I've already had one kid die during that round trip.  Clearly kid is dying so what the hay, maybe something fixable . . . while we're trying to gather up all the lines and tubes and baby, head nurse pulls a classic nursing-here maneuver by scolding the mother as she is gathering a wrap to cover the baby in the rain, "what are you doing with that, aren't you listening? what's wrong with you?"  I walk up to him very close, very quiet and using all linguistic markers of respect in Sango, say "Please do not get angry with that woman on the day her child dies."  He nods ok.

      X-ray shows tension pneumo total left lung collapse.  We return to ward and surgeon hooks up a big syringe to the chest tube.  He withdraws as much air as he likes, no resistance.  Every time he does so, infant perks up for seconds, then eyes close breathing strained.  So, it's a broncho-pleural fistula.  Nothing to do, untreatable here.  We call "mental health" (they are great!) to discuss with mother and father (he looks like Tupac Shakur, I passed around a picture people agree) advising them that prognosis is grim, but we will not withdraw care if that's what they want, and hope for a miracle.  They are quietly thankful.  I advise night covering med student that I expect infant will die.

     Next morning - she's awake! Alert!  Screaming bloody murder when mom stops breast feeding!  We have left the tube at "built in valve" resistance but no negative pressure, hoping that a tolerable tension pneumo will seal the fistula.  This seems to have worked.  Odds stacked against her, but hey you never know.

     I am covering the malnutrition ward, also.  There is a scrawny kid who's mother does not talk to me much.  I am told she has "mental problems."  While I am seated at the front of the room the nurse says that the mother just slapped the child (an infant) because she soiled her bedclothes with diarrhea.  Another patient's mother just next to me says, "that woman is going to kill her child."  The woman in question storms out of the room in frustration.  The child cries herself rapidly to sleep.  I summon "Mental Health" staff to ask what our child protection options are.  The answer, None.  Patient is well known to them, seriously mentally ill, estranged from her family who fear her and will not take the child because of that.  Patient has been offered antipsychotics but refuses.  Mother returns, trying to feed infant fortified milk from a cup.  Infant is coughing and choking and gagging, mother just keeps pouring faster and pushing harder, down on her arm I fear it will snap.  I run over and say "hey hey, that must be so frustrating I am so sorry!  Maybe we can help you, you're doing such a great job!  How about we switch to tube feeds?"  Nursing tells me, we've done that before she keeps pulling it out.  I ask them to bear with me, watch. . . I walk over to them and in a loud, angry voice say, "You guys!  If Mom says she wants a feeding tube, you give it to her!  I don't want to hear any more back talk from you!"  I lean closer to tell them in a whisper, 'we're putting on a show, just go with it.'  I return to crazy mom's side, she says yes let's do the tube.  Best part of the day, the Mom who said crazy mother was going to kill the child says to me, "you are so funny.  We love what you do."  I ask bystander if she would be willing to take the child home with her - the woman says she already offered, but the mom refused.  Wow.  And, horrifyingly yet predictably, the abused child embraces her abuser.

     Back at the house, my boss's boss (who is also my direct boss because my regular boss is on extended vacation and I'm in his post 'ad interim'), a Central African, says that sadly there is no child protection structure in this country, and lethal abuse and neglect is not rare.  NTD.

  On the plus side, a view from the vehicle of downtown Bambari.  If you know the town, ahead in center is the pillar of the "round point" (traffic circle), turn right there and you will go past ENI on your left.  They say two years ago bodies left on this road and gun battles not rare.  Now - a bustling metropolis!