The day we ran the clinic

So I think it's important to appreciate who's on my trip and our situation. 

Dr Jan is at home recovering from a fracture or rather a compression fracture and trochanter injury.

So basically Joy Hospice is being run by the clinical officers an nurses. Clinical officers are sort of like pa/midlevels in the u.s. this is usually not a problem at a level two health center buuuuuut here's our census :

40s yo guy with recently dx aids , with night sweats and poor po despite being on art and broad spectrum abx.

80s yo lady with severe asthma on 30 mg of prednisone , oral salmuterol , and nebs spaced anywhere from q 11 to q4. This morning she was newly hypoxia to high 80s, auto peeping and tachypneic to 30s.

80s yo lady with ccf ( congestive cardiac failure ), kaposis sarcoma ( non HIV), hx of pud. P/w weakness and fatigue . She was found to have a high of 6.6 yesterday with black stool but doing okay. We had started a ppi and hoped for the best today. However, she was looking shocks with cool extremities , white conjunctiva and looking horrible. Our c.o. Told us her o2 sats were 60s before we rushed in to assess her. In short , her poor perfusion gave a poor pulse of read but my main concern was a gi bleed as she had inc stools overnight that were loose and black with left sided abdominal pain. 

30 yo f with metastatic ovarian cancer with malignant ascites and multiple implant sites in adores was referred to us by the bigger hospital " for morphine " and evaluation with very little explanation of her disease. 

50 yo f with metastic breast cancer who ran out of her pain meds and was constipated along with Complaints of leg parasthesias .

Solo that's our ward. Day 3 on the job and we were left to run this ward and make decisions. Let me first say that I am working with two amazing residents, almost attendings ash and court who basically helped me run this semi adult icu service from a small clinic in Mbale , uganda . We rounded , did our own vitals , made plans then met dr jan at home for lunch and to discuss cases. Dr jan basically agreed with our management which follows:

1.Gentleman with aids , I was concerned for a tb coinfection thought he had no cough. However he had no sputum so we couldn't do an afb and ironically to run the free gene test at the  regional hospital we'd need sputum . The other differential would be an IRIS type reaction .

2. Lady with asthma . We basically made her q3 nebs , adjusted her steroids to adult dose and give iv aminophylline with great improvement . Hypoxia had resolved by end of day. 

3. 80 yo lady with ccf/ pud hx. On my way to dr jan...I smell and saw the malena personally. After going back and forth wi the staff because her hgb was 6.6 (from 9s one month prior)apparently the hospital will usually send blood only if <5 . We basically got blood sent , obtained an iv , started 2 units prbc with lasix between and prayed for the best . ; TLDR: I managed a gi bleed in outpatient clinic. 

4. 30 yo female wi met ovarian can Er. Basically I had to discuss her whole case with her . I had to explain how bad her cancer was and that she would die from it. I explained her ascites would keep coming  back  with this cancer . I explained that we should focus on treating her pain and letting her be as functional as possible . We even assessed her home situation which we realized she lives with her husband who works most days and can't tend to her ..as a terminally ill patient . So after discussing the case with dr jan   , she told me to tap the ascites if I felt like it . No , this isn't stony brook. I don't have a sonosite, I don't even have a paracentesis or thoracentesis kit. In short dr jan told me to sort of make an iv / tubing / bucket work for me . So with the help of Ashley , sweating my --- off I attempted to canulate her abdomen with an 18 gauge needle. Then I would hook it up to an iv set and basically reverse a traditional iv drip to drain this to gravity. Long story short, after much anxiety and a bent catheter on the first try I was able to drain 2 liters of straw colored ascites to the relief of the patient . Sadly   , after get distended and Tympanic abdomen went down, we were able to see the large left sided abdominal mass ....the source of her terminal illness. Sad. 

Fun fact   , oral  morphine is provided free by the govt for palliative care. It comes in three concentrations that are color coded/dyed. 

Green (5mg/ml)  Red (50mg/ml) Blue (100mg/ml)

All in all , one of the most memorable days of my life.