Ups and downs

Today was definitely a bipolar sort of day...

The down part was my morning in neonatology, where 25% of admissions die. They have 15 broken incubators (old ones donated by a French hospital in Dijon that didn't need them any more... unfortunately, since they're old there's no one to maintain them even in France, much less here!), a few cribs and a working bili light. And a sink, table and scale. During the day now the ambient temperature is OK for the prems - its above 35C... but at night it sometimes goes down to 16C which is less than ideal without working incubators.

But worse then the lack of equipment is the lack of making the most of what they do have. And medications not being available because the parents can't afford them. An example of the former... (sorry, this is very medical)... a 5.3kg baby was born on Friday by cesarian section... and from then until this morning the baby got neither food (as mom is in post-op) nor IV glucose (because the interns / nurses didn't think of it)... so by this morning the baby was barely responsive and jittery all at the same time... and then when this information came to light, instead of urgently infusion some sugar, the intern kept flicking the kid's heel to try to get him to react... for 15 minutes. Despite my repeated pleas to start giving the dextrose (which by fluke we happened to have right on the examining table). (For those non-pediatricians... very large infants are at high risk of having very low blood sugars and need frequent feeds and sometimes IV sugar to prevent severe low blood sugar and even brain damage). It was really frustrating!

So after that very depressing morning in the neonatology ward, I had a really uplifting meeting with Pr. Nacro, the chief of pediatrics. Basically, we reaffirmed that we're on the same page for priorities and goals with respect to treatment of HIV + children... and most importantly that he will let us start seeing the HIV patients as early as next week to start decreasing his clinical load and prepare for the inlflux of kids that we expect to get once we start wider scale testing up and running.

Next week!!!!!!!!!!!

(Actually, I'll be in Ouaga next week, so it will be Leah and Suzanne who likely will start).
Pr. Nacro can be a little hard to communicate with at times but he is really on top of things and is such a dedicated worker. And he has the connections that without which we would never, ever make any progress.

So suddenly, I expect life to get quite a bit busier. And I'm all for that! Observing in someone else's unit is OK... but its often hard to not do things our way, to just accept the way things are done. Whereas we can provide whatever level of care we want in our own practice. And we can continue to work towards ameliorating the standard of care in the service in general. But that requires interest on the part of the local staff, which can be a challenge.

One other encouraging story is with respect to Vitamin A... at Johns Hopkins we learn a lot about how Vitamin A is the wonder drug, the most cost-effective child survival intervention there is. Here in Burkina Faso, it is theoretically given to kids every 6 months on vitamin A campaigns (with excellent recorded coverage rates.... I have serious, serious doubts that they are as high as they say they are!). Because its given (in theory) in peripheral clinics to all kids, its not available in hospitals. Even for kids with measles, severe malnutrition or vitamin A deficiency.

When I arrived here, I kept trying to prescribe it with limited success. Kept talking about it, suggesting it etc. Apparently the staff went to Pr Nacro to ask "what is she on about" and he totally supported me (thankfully!) and they started to believe it.... then we managed to borrow some Vitamin A from a peripheral clinic so we can at least give it to the malnourished kids. And people are thinking of it a bit more now. And the other staff pediatricians - especially the Urgences doc - are encouraging the med students to give it. So, I think vitamin A is making its way into CHU-SS.

I have to get excited about baby steps... because that's all we have. Overall, during the last few weeks it has been really discouraging to keep trying to get things organized, but the renovation of the transitional clinic space is going to be a long time in coming, the translation of our curriculum is delayed, the national committees for training and guidelines are excruciatingly slow, and I haven't the foggiest idea how to deal with the corruption and need for "motivation".... so to have a few positive steps is really, really exciting. Maybe, just maybe, we're getting somewhere.