Bongo so awoko mingui (that fabric is very soft)

 

I recommend a holiday in Cambodia.  The kids do not like the Dead Kennedys song, but the country I think amazed us all.  The ancient temples, the agreeable people, the genocide memorials all warrant visit.  More bats roosting in trees, I guess this is a thing, who knew? not me.

Cambodian silk, Central African tailoring, and behold.  The tailor was amazed at how soft the fabric was:

I have another bolt different colors/pattern, I'll probably go for another of the same model.

Back in Bambari, things have evolved.  My immediate supervisor is gone, here now a dynamic, motivated and intelligent replacement.  Can we get anywhere on meaningful improvement in my remaining 2 months?  Time will tell, odds not in our favor as hierarchical obstacles abound.  But at least we can try.

I will repeat our "don't scold the patients and families" training, which featured role playing (by me as an over the top irate nurse) to much general amusement. 

Here is the announcement, and a sample of the snacks (kuru kuru, peanut sticks) which probably made everyone more inclined to swallow my theatrics, and the message:

 

There follows densely medical stuff, feel free to skip

I am now in malnutrition ward, less intense allows time to work on the systemic improvement projects.  Also enjoying more trips to the OR for c-section deliveries.  3 deliveries today, 2 of which stillbirth.  Walking by the ICU, doctor had left for lunch (this is normal); they ask me to look at a kid arrived 1 hour previously from ED - he has severe respiratory distress and shock and hypoglycemia.  Bolus dextrose, bolus Ringers and Mom does not seem to get the severity of the illness, or maybe denial.  I go to summon Mental Health to talk to her about possible death of her child today - by the time I return the kid is already dead.  The kid was probably in shock since the ED, not treated aggressively.  We will need to work on this.

My replacement in ICU is an excellent Central African doctor.  She cares about the patients, works hard and thinks deeply about their course and treatment options.  I have praised her multiple times, to her directly and to others, but she thinks I am kidding.  She asks me about a challenging case of a febrile  child in prolonged coma and status epilepticus despite multiple antibiotic courses.  I advise her to stop the seizures by adding agents until controlled (we now have phenobarbital IV, levetiracetam IV and carbamazepine po) then peel off agents - she agrees and seizures stop.  I suggest LP for TB PCR (our lab expert visiting from Bangui says our GeneXpert machine can process CSF) and cell count, then start TB drugs.  Lab refuses to process the PCR (these things happen. . .) but CSF WBC are listed as 2+.  So how about she start the TB drugs?  Without other evidence of TB she is reluctant.  We review the differential diagnosis which includes really only 3 disorders treatable here - HSV encephalitis (nothing else going for that), otherwise resistant bacterial meningoencephalitis, and TB.  She wants to go chloramphenicol (we actually still have some) which I agree is reasonable given documented multiresistant bacteria in CAR, but suggest she do TB tx as well, which she declines.  I would consider acyclovir too which we have sometimes but that will not fly with her.  We agree that a trial of chloramphenicol should not last too long before declaring insufficient progress and starting TB tx.

Day 3 of chloramphenicol I pass through the unit.  Patient is still on chloramphenicol not TB tx, still coma, still febrile.  Mental note to discuss with the doctor; when I return that afternoon, the child is dead.  I start discussing if perhaps this is reason to consider earlier initiation of TB treatment in such cases.  This is a bad idea, I can see (and should have seen) as she is taking the death hard.  I try a rapid about face and praise her effusively - it is too late, she is not hearing the praise.  I stop, and return later simply to thank her for all her hard work and thoughtful care on the child's behalf; no go.  Another doctor tells me later she was crying, about how I criticized her.  Must admit, I messed up on this one.  I will attempt "service recovery" tomorrow.

One of our drivers assures me that yes, they still make douma (mead, i.e. fermented honey) here.  He says he can get me some tomorrow; I hope so.   Our Tunisian surgeon trained in Russia developed taste for it there, we'll see if it measures up to his standards.