April in Uganda

The PURE team has returned to southwestern Uganda during an uncharacteristically sunny April to continue our ongoing ultrasound capacity-building at Mbarara University of Science and Technology. Following a series of meetings and planning sessions in Kigali, Rwanda our team of four trainers, led by PURE founder and lead trainer, Dr. Trish Henwood, crossed the verdant jungle border to join Drs. Derek Harborne, Julius Mugisha and Lisa Bebell at the Mbarara Regional Referral Hospital (MRRH).

After a brief celebratory reunion, we set to work, preparing for 2 days of intensive, multidisciplinary ultrasound seminars. Within a frenetic 24 hours we’d managed to wrangle a projector, a reliable generator in case of outages, training space in the surgical skills center, a catered lunch for our eager trainees, and volunteer models for practice scanning. The speed and success of our preparations were no doubt thanks to the hard work done by Drs. Bebell and Harborne in anticipation of our arrival.

We spent our first day with the MRRH obstetrics and gynecology department, a dedicated group of doctors, nurses, and midwives with whom PURE has worked before. ‘Enthusiastic’ doesn’t begin to describe our reception by the department. The audience of 25 was more than double our expectation, thanks, no doubt, to the usefulness and popularity of PURE’s prior training endeavors! Lectures provided by myself, Dr. Brian Cone, Dr. Alissa Genthon, and Dr. Julius Mugisha were punctuated by two lengthy, hands-on scanning sessions with volunteer patients from the obstetrics ward.

We spent day 2 with our already ultrasound-savvy ‘local champions’ from the medicine and surgery departments reviewing key topics in point of care ultrasound (DVT, soft tissue, IVC assessment for volume status). Later, Dr. Alissa Genthon introduced a new application to our trainees, the FASH exam (focused assessment with sonography for HIV-associated TB) pioneered by Dr. Tom Heller. The remainder of our second seminar day was spent practicing scans on each other before marching out to the wards to again supervise scanning on volunteer patients.

The conclusion of our seminar days was bittersweet. While training was a resounding, well-attended, and happy success our team parted ways shortly thereafter. Drs. Henwood and Genthon headed back to Rwanda to continue our ongoing training at CHUK in Kigali, while Dr. Brian Cone and I will remain here at MRRH for the next several weeks, providing ongoing bedside teaching, supervision, and spreading the gel-y ultrasound gospel with our champions in OB, surgery, medicine and pediatrics! Stay tuned for more updates in the weeks to come.

January in Uganda

January saw the successful wrap-up of Phase 1 of the PURE/MGH point-of-care ultrasound project in southwestern Uganda at Mbarara University of Science and Technology (MUST). Project trainers included Drs. Adeline Boatin, Lisa Bebell, Trish Henwood, Vicki Noble, Katie O’Brien, Derek Harborne, Brooke Hensley, Nicola Baker and Julius Mugisha.

Prior to project kick-off in September 2014, a PURE-led needs assessment in early 2014 demonstrated that clinicians from the Obstetrics-Gynecology and Emergency wards could benefit most from immediate training and access to point-of-care ultrasound. To that end, clinicians were elected by local leadership from the surgical, medicine, pediatrics and ob-gyn departments. Clinicians learned to utilize bedside ultrasound to identify a variety of potential life-threatening conditions such as tubal pregnancies, high risk pregnancies, trauma injuries such as bleeding in the chest and abdomen, advanced heart failure, fluid in the lungs, abdomen and hearts of AIDS patients, and blood clots, to name a few.

Supervised practice makes perfect, so trainees then received ongoing 1:1 bedside scanning practice with expert PURE/MGH trainers every 6 weeks for the duration of the project. Input from trainers and structured assessments of skill retention – also done every 6 weeks-showed that our 18 clinician trainees are amazing! Despite tremendous clinical work loads, their ongoing commitment and enthusiasm to point of care ultrasound was inspiring!

They share stories already of patient lives saved because they used their new POC ultrasound skills. ‘Joseph’ is a 24 year old male with shortness of breath after a fall from a motorcycle. He came to the hospital critically ill. Clinicians were extremely concerned about his breathing status and, in particular, for perforated lungs. Time was of the essence and x-ray unavailable. Bedside ultrasound showed that both lungs were collapsed, a life threatening condition. A tube was placed in each lung and the patient survived and discharged home smiling one week later.

Another patient, ‘Peter’, is 38 years old with AIDS. He was admitted to the medicine team also unstable and unable to breathe well, the reason for which was unknown. The patient did not improve with typical management. A bedside ultrasound was done because the clinicians were perplexed. This ultrasound showed an enormous amount of fluid surrounding the patient’s heart: a life threatening condition for this patient. Because of this ultrasound finding the patient underwent removal of the fluid and survived. These are just two of the success stories rapidly accumulating since the PURE/MGH trainings began 6 months ago!

At the completion of the phase 1 course, along with enormous smiles and hugs from our new colleagues and trainee friends at MUST, 2 questions were repeatedly asked: “When are you coming back? And when can we learn even more?”

With the financial assistance from gracious donors world-wide we hope to return to MUST throughout 2015 and not only continue current training efforts with our initial group of clinicians, but also expand efforts to include more extensive ultrasound-in-trauma training and obstetric training, and a train-the-trainers course for our sono-stars of course!

An enormous thank you to everyone who made this initial effort a huge success AND to those who may contribute in the near future!

 

December Update

This fall has marked a very busy time for PURE with members of our ever-growing team scanning and teaching ultrasound in Ethiopia, Uganda, Rwanda and Liberia simultaneously!

In October and early November we had residents and fellows, Drs. Phindi Chowa, Kenn Ghaffarian and Mike Rubin join the team. They worked with our Rwanda programs coordinator Dr. Paul Pageau and made good progress with our large training cohort in Kigali. Paul and one of our top Rwandan PURE trainers, Dr. Gabin Mbanjumucyo, then travelled to represent PURE teaching at the ultrasound pre-congress for the African Federation of Emergency Medicine conference. Gabin was elected as Rwanda’s representative for the newly formed African Ultrasound Committee, and PURE’s President Dr. Trish Henwood will serve as International Advisor to the Committee.

In the meantime, Drs. Katie O’Brien and Lisa Bebell were busy in Mbarara, Uganda continuing to work with our first group of trainees from a cross-section of specialties at Mbarara Regional Referral Hospital who have been making great process!  Late November found PURE leaders Drs. Megan Leo and Dave Mackenzie joining Paul and veteran sonographer David Adams in Kigali to lead our second annual train-the-trainer course as we continue to help build skills and contribute to local teaching capacity.

Trish was across the continent in West Africa, and grateful to secure a Micromaxx generously donated to PURE by Sonosite. She was teaching colleagues and using point-of-care ultrasound to assist in the care of the patients she was treating while working clinically at an Ebola Treatment Unit in northern Liberia with International Medical Corps. She found there were many ultrasound findings that helped patient management and give a better idea of pathophysiology, and she is hoping to return to the region to continue the work soon.

#GivingTuesday is a great opportunity to support PURE’s important and broad-reaching work planned for 2015 and beyond. Please contact us if you have interest in getting more involved with our work.

November 21st

It’s been a busy week of ultrasound education for PURE staff and trainees. Resident physicians who have been learning point-of-care ultrasound with PURE trainers changed roles this week and have done a fantastic job putting on beginner ultrasound courses for 4th year medical students. The residents participated in a train-the-trainers course this week at Centre Hospitalier Universite Kigali (CHUK), one of Rwanda’s main teaching hospitals. The train-the-trainers course provided the residents with a chance to learn approaches to teaching ultrasound at the bedside, as well as to learn some of the skills and steps required to put on an ultrasound course.
The residents did an outstanding job teaching over 100 medical students this week, delivering lectures and hands-on education to introduce physics and instrumentation, the FAST exam, and echocardiography. The response from the medical students has been overwhelmingly positive as they anticipate beginning their internships next year, and course evaluations have been filled with enthusiastic requests for additional training.
The residents have also had the chance to learn some advanced ultrasound skills with PURE trainers, including volume status assessment, nerve blocks, and vascular access. We’ve had some great scanning sessions on the wards and in the ED at CHUK and have made a number of diagnoses for the clinical teams.
Today we’re on the road south to the Centre Hospitalier Universite Butare, where the residents will deliver another course for 40 medical students. We’re looking forward to working with another motivated group of students, and to continue working to improve the skills of residents and students alike.

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Intensive training blitz: Week of Oct 20th

US training has intensified this week in Rwanda with the addition of 2 new PURE instructors. Welcome to Mike Rubin, Faculty at Beth Israel Hospital and future Fellow in PoCUS at the University of Ottawa. Also new on the Rwandan PoCUS scene is Kenn Ghaffarian from the University of Pennsylvania Emergency medicine program.

Kenn Ghaffarian getting the image with internal medicine residents in Butare.
Kenn Ghaffarian getting the image with internal medicine residents in Butare.

In addition to a bedside ultrasound training blitz this week in the ED for residents and GP’s the PURE team went on the road with an introduction to cardiac PoCUS course in Butare on Thursday. The Internal Medicine residents were quick learners as we went from classroom to scanning their patients on the ward. There was opportunity to address their focused clinical questions and further integrate PoCUS into their practise. This proved to be a very effective approach for these trainees. It has been most fascinating working with a wide range of specialists to find the most relevant PoCUS indications for their unique and resource limited work environment.

Kenn Ghaffarian guides Faida, EM resident, to a better image in the ED
Kenn Ghaffarian guides Faida, EM resident, to a better image in the ED

On Friday the PURE instructors brought their PoCUS expertise to a Surgery course back at CHUK. PURE joined forces with local faculty surgeons and radiologists to provide a crash course in US guided core needle biopsy for all surgery residents in Rwanda. PURE forces were strong enough this week to continue Internal Medicine PoCUS training while providing crucial instruction at the surgery course. What a great team!

Paul Pageau
PURE Coordinator
Rwanda

‘Building capacity’

PURE continues to develop quality PoCUS work here in Rwanda.The foundation of building capacity has been the PoCUS education program which has been tailored to the needs of each specialty. As a result, we have identified PoCUS champions in the different specialties.

Paul Pageau Scanning with Hippolyte Bwiza Muhire a keen and highly motivated Pediatric resident.
Paul Pageau Scanning with Hippolyte Bwiza Muhire a keen and highly motivated Pediatric resident.

Each group of specialists are meeting at least once weekly to define objectives, expand skills and learn how to effectively integrate PoCUS into their unique clinical setting. For example, the team of one junior and two senior resident surgeons have already been meeting regularly and then applying eFAST, advanced cardiac, and the RUSH exam to their clinical work. These surgeons are interested, engaged and eager to continue to develop their PoCUS skills.

Internal medicine and Pediatrics have also begun advanced training. The Senior internal medicine residents are meeting weekly with a focus on incorporating PoCUS to expand their physical exam. Pediatrics is a unique mix of faculty and residents, with an initial focus on the pediatric acute care setting. Local faculty, Tim Walker from internal medicine and Samantha Rossman from Pediatrics deserve recognition for helping set up these sessions.

Lastly, ten EM residents are currently undergoing an eFAST credentialing process designed by a collaboration of local EM faculty and PURE faculty. Special thanks to Simon Pulfrey, and the PURE team of Laura Diegelman, Raja Rao, and Colleen Holley for developing a program that is currently being executed.   The EM residents are now benefiting from an innovative and unique approach to credentialing in a resource-limited environment. It includes OSCE assessment, supervised scanning and an independent log book.

Looking forward: PURE plans to design and conduct a PoCUS course specifically for Doc IV’s before they begin to provide care in the district hospitals. Also on the horizon is collaborating with local faculty to provide PoCUS training to GP’s already practicing at the district hospitals.

September and October have been productive months for PURE work in the land of a thousand hills.

Paul Pageau
PURE Coordinator
Rwanda

October 10th

It has been a very busy month in Mbarara, Uganda!  We have just wrapped up round 1 of point-of-care ultrasound training at Mbarara University of Science and Technology. With the tag-team efforts of Drs. Lisa, Adeline, Trish, Derek, Julius and Katie, 40+ ugandan clinicians were provided with a hands-on introduction to POC ultrasound. Our trainees included clinicians across specialities, including Surgery, Medicine, Pediatrics and Obstetrics. Machines graciously donated by Sonosite are now on-site and available to clinicians. Logistics of training such a large crew has been exciting and challenging: take a look at the cage we had built for our ED machine!  The enthusiasm of our new Ugandan friends and trainees is fabulous and we look forward to ongoing collaboration in the upcoming months.

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September 16th

…And the East African trainings go on! Last week PURE officially embarked on a longitudinal point-of-care ultrasound training project in Mbarara, Uganda. Phase 1 of the training is in collaboration with Massachusetts General Hospital (MGH) Department of Emergency Medicine and MGH Center for Global Health.  Last March, Trish visited Mbarara Regional Referral Hospital and during her needs assessment recognized that imaging services- ultrasound included – are desperately needed.  Most notable at that time was the lack of access to obstetric ultrasound services for pregnant patients. With over 30 babies delivered daily, lack of prenatal ultrasonography is tragic. The obstetrics department was immediately identified as our first ultrasound priority for educational efforts. Further investigation revealed that access to radiography and CT services are highly unpredictable due to frequent power-outs and governmental shortages. Our conclusion: all departments at MRRH are in need of and enthusiastic to learn basic point-of-care ultrasound skills. Thus began PURE’s latest ultrasound endeavor!

Over the next six months Dr. Katie O’Brien will be coordinating and overseeing the trainings in Mbarara for PURE.  Our efforts kicked off with a 2-day course for pediatric, surgery and medicine residents.  Observed clinical skills examinations (OSCEs) for our trainees prior to the course demonstrated that most folks were brand new to ultrasound yet highly motivated and enthusiastic = ideal students! The trainer team included Drs. Derek Harborne (UK emergency medicine based in Mbarara), Julius Mugisha (Head of Radiology at Mbarara University of Science and Technology), Lisa Bebell (MGH infectious disease/critical care), Katie O’Brien and Trish Henwood.  We focused on contextually relevant, basic applications such as E-FAST, basic cardiac and evaluation for deep vein thrombosis. After just 2 days of training our 6 resident trainees were scanning like pros!  PURE trainers will work individually with all 6 trainees in the upcoming months to ensure competency, as we investing in this group heavily with hopes they will serve as future PURE trainers in Uganda.

Next up was Point-of-Care Obstetric Ultrasound. Trainees were a mixture of obstetric residents, faculty and midwives. The course taught by Drs. Katie, Julius, Lisa and Adeline Boatin (MGH ob-gyn/global health) focused on FAST and basic antenatal ultrasound. Another 2 day course was undertaken and 14-16 ultrasound disciples born! Similar to the non-ob trainers, we have worked with department leadership to identify 8 of these trainees to be our focus with whom our trainers will work individually through January 2015.  We anticipate that with longitudinal skill development, they can become fabulous obstetric sonographers and future PURE trainers at MRRH.

PURE thanks all trainers and trainees for a wonderful first week of ultrasound training in Uganda!

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September 12th

Wednesday afternoon the surgeons were introduced to our homemade Jell-O phantoms.  The phantoms worked out great!  They provided the surgeons with the hand-eye coordination to navigate the needle under the probe while trying to hit the lumen of the penne pasta.  This will be a very important skill for them if they need to use ultrasound when placing a difficult peripheral or central intravenous access line, or trying to perform an ultrasound guided procedure or biopsy.   The surgeons already had an amazing understanding of special anatomy so they caught on quickly and were able to obtain great ultrasound images.  Thursday was our first day in the ED working with the residents to develop their skills.  Dr. Paul was even able to work in the ICU with one of the emergency residents on his off-service rotation. Drs. Colleen and Laura worked one-on-one with 3 of the residents in the emergency department. Friday we continued to ultrasound in the emergency department and the ICU while Dr. Trish coordinated several meetings to discuss ongoing projects.

Overall, this has been an amazing PURE training trip in Rwanda and a good start to the efforts for this academic year.  We were surrounded by enthusiastic residents and faculty whose only negative comments on our evaluations was that they wish they had more time with us to learn and practice ultrasound!  Dr. Colleen will be on hand to continue scanning next week and Dr. Paul will take over until the end of November.

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September 9, 2014

So far this week has been packed full of ultrasound!  Monday we hit the road to Rwamagana and were well received by a large group of nurses.  After a beautiful drive through the countryside we are reminded why Rwanda is called ‘the land of a thousand hills.’  These nurses are undergoing an accelerated training program on non-communicable diseases and they will soon be leaders in their 10 district hospitals.   They were excited to learn the basics of ultrasound and were especially interested in the heart.  In order to keep things lively the nurses even treated us to a beautiful energetic song midway through the day (see clapping photo below!).  Tuesday we worked through plans to credential all the emergency medicine post-graduates with the EM faculty.  We then spent some time in the ED, where Drs. Paul, Laura and Colleen will be working later in the week with the emergency medicine trainees refining their skills.  We were running low on ultrasound gel and had some xanthan gum that we sent from the US by medical student Matt Smith – thanks Matt!  Last night we made a batch of ultrasound gel by mixing 2tsp xanthan gum with 1tsp salt then quickly stirring it into 2c boiling water.  After stirring until it all dissolves let it cool and thicken.  While we were in cooking mode, we wanted to challenge the surgeons who will be joining us this week with some homemade phantoms.  We created two phantoms using Jell-O and penne pasta to simulate a vessel lumen.  Stay tuned to see how the surgeons performed using our Jello-O phantoms!

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Dedicated to improving ultrasound education in the developing world