Hmmm, I don't remember learning this in residency!

Aaron here. So I've had a few people ask what kind of stuff I'm seeing here in Kenya. Honestly, I'm still not completely sure yet but I'll share some of my patient encounters with some added details for you medical minded out there.
I have been blessed to be "eased" into medicine here. I took the 1st week to get settled in our house, adjust to the time change and adjust to being at 7,000 ft elevation ( after playing some flag football yesterday I'm still not sure I'm adjusted!). Anyway, the first two days I spent following Kyle Jones around. We saw the men and women wards (maybe 6-8 patients each ward) then the peds ward (10 kids probably) Then OB (4 or 5 patients there post partum from C-sections). Also saw the nursery patients- you don't see the health babies here only the ones with problems. Then we went to the outpatient department and saw some patients waiting there to see the doctor. Also had 2 c-sections sometime during that 1st day.
The next day was similar then it happened...I was on my own! Well I still could call Kyle if needed but he's a busy guy and I didn't want to bother him on every patient.
So I started with the men's and women's wards and here is what I saw:
1. 70 year old man with an esophageal mass on EGD (the surgeons do those so that's great). He had been vomiting blood for months and unable to keep any food down during that time. He had 2 episodes of low blood sugar the night before, they use a different measurement for blood sugars that I'm still getting used to but he was low. Kyle had placed an external jugular line the day prior to get him some sugar as he for some reason had no IV line at the time of his low sugar. The day I saw him his family felt he wasn't acting correct and he seem to be somewhat delirious. but his urine output was only 300cc for the past 13-15 hours total. He was talking out of his head, vomiting blood and not getting any nutrition due to the NG tube not being able to go past the mass. His lungs sounded like there was a monster in there trying to get out with every breath!
So after standing there for a while and not sure what to do I prayed with him and his family and made some fluid adjustments, checked that he was on abx for aspiration pneumonia and went to my next patient praying he had something I could "fix" with medicine.
2. Next patient is a newly diagnosed HIV patient with cryptococcus mennigitis confirmed with india ink on lumbar puncture. He's on all the anti-retroviral therapy plus high dose fluconazole. The nurse asks if amphoterican B would be good for him... I smile and say let me check my book (oxford handbook of tropical medicine...every page I now turn to is something I have seen or treated!) so we changed him to Amp B per the oxford dosing guide.
3. Next patient is a community acquired pneumonia, seems to be improving but was also newly diagnosed with HIV.
4. Next man is an 80 year old man that has been admitted within the last few hours and is waiting on me to diagnose and treat him. complaining of hurting all over, vomiting for 2 weeks and diarrhea. Fever. I'm thinking some parasitic disease or Typhoid or both. He also has urinary retention and we can't get a cath in so he goes to the OR.
5. Final male patient has pneumonia and is improving but had a TIA yesterday but going home today
So that took about 2 hours... on to the women

1. 37 year old HIV patient with sepsis but we can't do any cultures so we don't really know what we are treating. Started on ceftriaxone but we ran out so started on sulbactamax (not a med we have in the US) but we ran out and now changing to Augmentin. Also has flagly, bactrim, fluconazole. She is in respiratory distress but on oxygen and evidently has been like this for a few days.
2. a 60 year old woman with a CT from a year ago from another hospital showing she has multiple brain tumors. She fell asleep 3 weeks ago and the family would like us to help her wake up. We all assumed she had herniated and is days from dying but now she is waking up and following simple commands.
3. New patient that needs to be seen. She is 24 and having consistent vaginal bleeding for 3 months. She decided to come in today due to heart palpitations and dizziness. hgb is 2.6 (normal is 11-14 and we transfuse anything under 7) I order 3 units to start with and recheck on her in 3 hours and she is still waiting on the blood due to lack of supply.
4. 45 y.o lady recovering from small bowel obstruction but now her hand where he had an IV is swollen and painful up to her shoulder and I can't feel a pulse so I send her to the OR where I do find a pulse with doppler but she still gets an I&D and started on cefuroxamine.
5. 18 year old with Typhoid doing better but HIV came back positive and she is in denial and doesn't want any labs (they always send a CD4 to Eldoret 2 hours away) or meds for it.
6. 40 year old with Giardia and Amobiasis recovering well on meds
7. 38 year old with cerebral malaria recovering on quinine.

Went back later for a 3rd C/S that day with Kyle, this one was thought to have a prolapsed cord but our Ultrasound machine isn't working, needs a new power cord. Baby heart rate is 175. Ends up being thick meconium. we suction at the cords and bag for 3 hours but the full term baby tires out and dies from likely meconium aspiration. we did give meds and fluids but we have no ventilators here which would have bought her some time at least.

So to make a long post longer let me share the outcomes of these patients. Sorry I'm being lazy you are going to have to scroll back and forth to see who I'm talking about. First the male ward

1.  Pt pulled out all his lines and ended up dying 2 nights later at the hospital
2. Improved then did worse then improved and was able to eat and set up then died 2 days ago at the hospital.
3. went home
4. just 2 hours after cath was placed in the OR he died probably from having massive amounts of vomiting and diarrhea
5.  went home

women
1. Was started on PCP treatment (high dose bactrim) then TB treatment due to an ESR of 60 but not able to get a sputum sample. XR showed pulmonary edema so she was also started on lasix. Then died 2 days ago
2. Is now more alert and getting feeds via ng tube but has some large pressure ulcers that need surgical attention
3. received 2 units but was waiting for her family to come give blood. started on an estrogen taper and last I saw her she was feeling better, and had been discharged but doesn't have the money to pay her bill so she just hangs out at the hospital until her family can get the funds to pay. She doesn't seem to mind though.
4. hand is healing and will probably go home soon
5. 6. 7. all went home

So again this is NOT what I learned in residency but I am thankful to be here and although it is still hard work I am glad to be a part of it...most of the time! I am also thankful that even though I didn't learn this in my training I did learn how to learn and how to use a history and physical to guide me in diagnosis. but is still have a LONG way to go. thank you for your prayers. I need them!

So I know it was long and boring for some of you but just for getting this far you get a pic of the girls!