Greetings from Bambari

 The honey beer from last episode was a fail - all sold out by 11am on a Sunday.  We go for the next best thing, millet beer (home brewed).  Tastes like a very un-hopped brown ale, a little nutty, a little smoky.  Even the Brit likes it: "Cheers, mate!" -John Edward, finest hospital facilities manager ever.  Also skilled in rugby and astral projection. I feared that my Fulani language acquisition project was shot, as my interpreter/informant/teacher Valentin, a Cameroonian native in Fulani was on an extended vacation.  He's back!  I can ask Fulani equivalent phrases of local speakers but parsing their replies is challenging.  Kind of pointing at something and saying "What is this in Fulani?" and the answer is "That is your left hand" but you don't know which word means "that is", "left" "your" "hand" or if the whole thing is just "hand" - you get the idea.  And the online Fulani sites use West Afric...

  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...

 I am in Bangui on my way to second vacation in as many months - an accident of administrative oversight that serves me well.  Meantime, some only in Bangui scenes: A COVID PCR is required to leave the country.  Why?  Because.  Anyway, to get one within the 72 hours from departure requires a visit to Institut Pasteur.  Quick, my NGO picks up the bill, and I am documented COVID free to leave.  But, has anyone ever seen this, a bunch of bats roosting in trees in the middle of the city? Probably 20 trees are full of them (all those black things hanging from the branches), just settling in for the day as I arrive at 7am.  Is this a thing anywhere else?  No one I asked has seen it elsewhere in the country. Folks have mentioned the front page NY Times article on Wagner/Russian forces here in C.A.R.  It is an accurate portrayal as far as my experience goes.  The article does not capture the soft power that USA still wields here, souve...

  After 4 months in Bambari - OMG Bangui looks like a massive bustling metropolis!  I am agape at the stocked shelves of the "Bangui Mall" which is a fancy department store featuring a well stocked supermarket on the first floor.  Prices are somewhat crazy but if you can find it at Safeway or Walgreens, you can find it at the Bangui Mall. I walk from one NGO residence to another which is allowed in daylight hours.  To my left, just 100 yards away - the Oubangi.   That's Democratic Republic of Congo on the other side of the river.  Nice to see it, even if the bustling part of the waterfront is elsewhere.  A few guys eating lunch next to their dugout canoe to my left (not pictured.)  My plane leaves for Richmond VA then NJ in three days, with me on it as long as I COVID PCR negative on Monday (why is a negative PCR needed to leave the country?  because!)  I will return in time for December 1 in Bangui - the national holiday commemorat...

  Great run over two weeks - zero deaths in the PICU.  I am perhaps jinxing things as there are one or two kids I hope to see tomorrow morning but would not surprise me if they don't make it.  Today two little kids out - home! - after long and complicated stays, the moms kind of bonded because they were the longest residents, seeing the other kids come and go.        More important, I finally got a yes from boss's boss for some projects, "I will support you" - a first.  Maybe I can get some real improvements started (not expecting to complete anything) of the many things pediatricians and visiting experts have been writing about for years, without anything actually getting accomplished.  And, most important - Thanksgiving!  I leave post in two days.  The trip from Bambari to Bangui to Paris to Atlanta to Richmond - few days there - to New Jersey -1 day there - to Paris to Bangui to Bambari will make 16 days away from the Hospit...

We exceeded one week with no pediatric deaths.  I do not want to jinx it, but still cannot resist celebrating our collective success, or good luck, or who knows what.  I am very lucky to spend every day in a place that is just so rewarding - the peds icu.  Because, beyond that. . . Looking towards pediatrics from the Peds ICU room walkway Pediatrics building ramp under construction - thank you NGO "Humanity and Inclusion."  And yes that young man has elaborate external fixator emerging from his fractured right arm.      I am now halfway-ish through my contract.  I have read the reports of the visiting experts, and my predecessors, who have revealed much to me by all the documents they leave on the laptop we pass down one pediatrician to the next.  The recommendations for meaningful improvement are the same, over and over.  I decided to see what my predecessor did, and why it yielded little to no lasting benefit, then try to move the ball...

     My European/American expat colleagues did not know about Mami Wata.  This (usually white, blond) female spirit lives within bodies of water, from which she can emerge to . . . well, it depends whom you ask, but it's usually not good.  In any case, she causes many problems here.  Back in Peace Corps days I recall that the fish-farming volunteers were challenged by reluctance of Central Africans to sleep next to their fish ponds to prevent fish theft, because of the risk of Mami Wata (knowledgeable readers feel free to correct me).  Also, when I briefly visited the hospital in my Peace Corps town of Berberati while in medical school,  the second most frequent diagnosis in the internal medicine ward was possession by Mami Wata (these were young men who spent several days catatonic, after which the curse lifted.)  The topic arose when I asked about the danger she might pose to fisherman in the nearby river (thankfully there are few Mami Wata...

      A culturally eloquent version of  Hear no Evil, See no Evil, the modification of which captures the principal of hierarchical deference found in CAR, and in my NGO.  On the wall in the CAG office (they provide HIV and TB meds for both inpatient and outpatients, they are super amazing folks) is a painting, a gift from a grateful client.  It reads, "The 4 secrets of happiness"  "Hear nothing" "See nothing" "Say nothing" and the added 4th, "which authority should you recognize."  While profoundly Central African, this attitude is not endemic to my NGO globally, perhaps only in this country, says the visiting expert consultant.  My boss, who has worked for this NGO across the globe, says no it's like this everywhere.      I walk into the surprisingly underfilled PICU this morning.  A child is in cardiorespiratory arrest.  He is not cold yet.  I know nothing about him.  Ambu bag is broken.  There is no...

Sorry to all for the long gap in posts!  I am now on a brief, asymptomatic COVID + isolation so stuck in my room and internet is cooperating.  Some odds and ends:      Just had a 5 month old reasonably well-nourished kid sign out against medical advice, which I can't fault because in 5 days of escalating care I got nowhere with her pneumonia, and her persistent severe respiratory distress.  I asked parents why now and they explained the diagnosis of "Fish Disease" which entails respiratory distress including skin retractions between the ribs, much like the gasping and gill slits of a landed fish.  The treatment, which was successful in the child's older sibling in the past, entails tying pieces of fish around child's neck and chest.  I offered to add the fish treatment to existing hospital-based care but parents declined.      The rag-rug is progressing.  I will probably call it quits in December and give it away.  It is b...

 Baby steps: PICU is admittedly not all that intensive, given absence of pressors, vents, portable imaging, CR monitoring, EKG, chem panels, micro studies, heme labs, specialists.  But, if we deploy everything we have with optimal efficiency, we can and do save some otherwise doomed kids. Night coverage is the "on call intern" who is a 6th year med student, covering the whole hospital. I have to schedule point of care hemoglobins and glucose checks, to identify actionable reversible decompensations before they become irrecoverable - typically when the kid presents agonal breathing they call the intern, do some hopeless cpr, maybe a round of epi then pronounce the kid dead.  So, scheduling interventions and tests when I am not there is high value but also difficult.  Previously, my yield on orders to be carried out in my absence was between 10-20%.  The "Nurse Activity Manager" came up with a brilliant idea - a whiteboard with tasks, dates and times.  We did...

 Non-medical blog post. The piquant mixture of every stage of human history, simultaneously in one place at one time:  Biblical plagues, medieval afflictions, colonial depredations, modern technology - in one day in Bambari. Today with help of my boss I go downtown to buy a smartphone - we negotiate a package deal, him and me discount.  My Galaxy is getting mildly glitchy and I need something to carry my to-do list and protocols around, snap pictures of x-rays.  For about $120 I can get 64 gigs storage and 4 gigs ram.  In Bambari!  It's a Tecno brand Spark 8!  The proprieter of the store is a little apologetic as he is still setting up display of his stock.  He agrees to a picture (of the display, not him).       He is "not from around here" so although his Sango and mine are equivalent, his accent is funky.  He speaks to his friends in Tchad-style Arabic, not Fulani, but he reports knowing Hindustani too.  Namaskar, ...

     On the way to work we turn left onto the main road and straight into a huge parade, marching into and around us.  An enthusiastic throng in support of an upcoming referendum.  Our driver pulls over to one side of the road.        One of the policemen escorting the paraders (you know them from their blue camouflage fatigues labelled "Police" and automatic weapons) approaches the driver's window angrily telling our driver that he is manifesting disorder.  The front seat passenger, a scrub nurse expat, starts explaining to the Central African driver how important it is to be deferential to an armed, angry law enforcement official, as if our driver reached adulthood in this country, alive yet somehow unaware of the danger such an encounter can pose.  Thanks, dude!  The moment, and the parade, pass quickly, and we continue on to the hospital.  I'm still not totally clear on when, or what, the referendum is to be.  The...

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...

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 ...

 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...

 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....

 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...

     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? A...

 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 pat...