April 2016: Kigali, Rwanda

PURE Ultrasound Rotation – CHUK Kigali, Rwanda

As emergency physicians we are no strangers to work in environments in which our resources are seemingly stretched to the limits. In my practice so far in the U.S., however, I have never waited three days to get a CT scan for a patient, or discharged them because they couldn’t pay for it. This can unfortunately be the clinical reality at times in Rwanda. In the bustling, frenetic, emergency department at the Central University Hospital of Kigali (CHUK), the ultrasound machines are in constant use. Patients are lined up in cots in the hallway, and more are always coming through the door, so there is pressure, as always, to make diagnoses quickly.

As an ultrasound educator with PURE, I worked with emergency medicine residents at CHUK, teaching them the basics of the eFAST, cardiac, lung, FASH and many other exams. In the first few days of the rotation we diagnosed miliary tuberculosis, liver and splenic abscesses, severe mitral valve stenosis, three cases of cardiac tamponade, and drained a 3L empyema. During this rotation the residents developed lasting skill sets to make quick diagnoses, perform procedures safely and effectively, and many times spare cost of imaging to patients. The very tangible improvement in quality of care that can be achieved through the skillful use of ultrasound in this practice setting is a testament to the enormous impact that ultrasound education can make.

Kavita Gandhi, MD
OSHU Emergency Medicine

March 2016: Kigali, Rwanda

Emergency Medicine Residency Ultrasound Rotation
CHUK Hospital in Kigali, Rwanda

While many resources are limited, one thing that is now more consistently available in Rwanda – both at CHUK and in the district hospitals, is bedside ultrasound. Providing the knowledge and skill set to use this tool appropriately has significant value as there is not access to portable x-ray and CT capacity can be intermittent. PURE is enjoying coordinating the new emergency medicine residency’s ultrasound rotation and for the past few weeks I worked on this effort. Emergency medicine (EM) is a new specialty in Kigali based at the University Central Hospital of Kigali (CHUK) hospital in Rwanda, an academic referral and teaching center.

CHUK Hospital, Front Entrance. Kigali, Rwanda

Hospital

 

 

 

 

 

 

 

The high volume of road traffic accidents makes the ultrasound training very important for the EM residents as it can aid in a much faster, and more affordable diagnosis of internal injuries (as there may also be payment issues with CT). During our scan shifts we diagnosed ocular injuries, fractures, pleural effusions, pneumothoraxes, cholecystitis, pericardial tamponade, small bowel obstructions, TB and cancer. Ultrasound in developing world often plays a huge role in cinching a more timely and accurate diagnosis.

Drs

 

 

 

 

 

 

 

 

In addition to using ultrasound in a diagnostic capacity, we also used ultrasound to guide procedures. We had one patient who came in with DKA, who was acidemic, hypokalemic and very ill appearing. She had waited overnight all night with no interventions, treatments or medication because the overnight team had been unable to gain peripheral access. In the morning, the residents were able to use bedside ultrasound to obtain a peripheral IV line and the patient ended up doing very well, and was discharged home 2 days later. We have also used the ultrasound to guide thoracentesis and pericardiocentesis procedures- primarily for patients with TB.

Bedside Ultrasound Teaching with Residents: CHUK

UsoundTraining

 

 

 

 

 

 

 

I found the use of ultrasound in Rwanda to be extremely rewarding, as we were able to change the course of treatment for multiple patients each day based on our ultrasound findings. In addition, the residents are eager to acquire the skill set, and are quick to learn ultrasound. While we are not necessarily going to get patients to come to the hospital earlier in their disease course, we can arm physicians with the ultrasound skills to more accurately diagnosis them when they arrive looking for help.

Kristin Dwyer, MD, MPH
Fellow in Emergency Ultrasound
Brigham and Women’s Hospital
Emergency Department
Emergency Ultrasound Division

January 18th: Mbarara, Uganda

The PURE team has made its return to Mbarara Regional Referral Hospital (MRRH) in Southwestern Uganda! Led by PURE co-founder, Dr. Trish Henwood, this team welcomes back Drs. Katie O’Brien (Kaiser Sacramento), Daves Mackenzie (Maine Med) & Newman (Penn) and brought in some new crew members: Dr. Elizabeth Hall (Penn), Simone Schriger, and me – Tony Joseph from Brigham/Mass General.

We hit the ground running with a full week of ultrasound training sessions for the OB midwives, house staff interns/residents, and surgical staff. Within a single day, physician trainees went from not knowing where the power button on the machine was to identifying subtle fluid stripes in Morison’s pouch and distinguishing free fluid fake outs in the pelvis from real pathology. Seminal vesicles will fool them no more!

Dr. Peter (surgical resident) was able to quickly utilize the knowledge and skills he gained on a Friday after he found himself on call in Accidents & Emergency on Sunday. A trauma patient presented with abdominal pain after a motorcycle crash, the FAST was positive for free fluid in the abdomen concerning for hemorrhage. The patient was taking to the operation theatre immediately and found to have a grade IV splenic laceration. Point-of-care ultrasound making a difference off the bat!

Many of the intern trainees quickly realized the power of ultrasound and started asking about other applications such as vascular access and hydronephrosis. With this level of interest, we expect their bedside scanning skills to take off quickly.

Meanwhile, the OB midwives and attendings who had received training on our last visit, showcased their wonderful OB ultrasound skills that they have been using all year long! Several 2nd & 3rd trimester pregnant patients from clinic volunteered to be scanned and the local staff correctly made biometry measurements to date the pregnancies.

We are also preparing for a trauma course in early February along with coordinating trauma surgeon, Dr. Deepika Nehra. Now that the physicians are getting the FAST exam down, they just have to learn A through E. More to come on that later…

Back to scanning!

-Dr. Tony Joseph

 

November Update

PURE has been quite busy in both East and West Africa over the last several weeks! Emily Douglass, MPH headed to Mbarara, Uganda in mid-October as our research manager to help hire our local research assistants and launch baseline data collection ahead of our trauma and E-FAST ultrasound training program starting in January. We now have three fantastic RA nurses from Mbarara, Christine, Judith and Anita who are keeping quite busy enrolling and following-up on dozens of major trauma patients each week. We have a large team of emergency ultrasound trainers coordinating with the surgery department in Mbarara and we are all looking forward to the early 2016 training effort.

Last week we met with the emergency medicine residency faculty in Kigali, Rwanda to finalize curricular plans ahead of ultrasound rotations that PURE is facilitating for the Rwandan EM residents from January-April 2016. Dr. Christina Wilson from Massachusetts General Hospital will be the lead-off trainer for the rotations and we are looking forward to so much focused scan time and skills building with the residents!

Dr. Anthony Dean was quite busy training at JFK Hospital in Monrovia, Liberia over the last month. He has been working with our resident trainees across specialties to continue building on the ultrasound knowledge that Drs. Alex Vinograd, Raja Rao, Trish Henwood and Laura Diegelmann introduced during trainings that started in July. Unfortunately, ultrasound training is on hold in the context of new Ebola cases at the hospital but we hope to resume in early 2016.

Please feel to contact the PURE team if you have interest in getting involved with our program building or hosting a fundraising event to support our range of health system capacity strengthening efforts.

The PURE Uganda Research Team: Emily, Anita, Christine, Judith
The PURE Uganda Research Team: Emily, Anita, Christine, Judith
The PURE Uganda Research Team
The PURE Uganda Research Team

September 19th: Liberia

This past week was busy and challenging!  The residents are getting much better at ultrasound and they are realizing all the potential applications of ultrasound on each of their patients. So, they are eager to see what they can find on their ultrasound exams and keeping the PURE teaching team engaged!  The week started with a teenager with an enlarging pelvic mass over the last 9 months without regular periods.  On physical exam she had abdominal protrusion about the size of 6-month gestation but a negative pregnancy test…on ultrasound she had an enlarged uterus and what appears to be a vaginal septum blocking menstrual flow.  She was diagnosed with hematocolopos and was taken to the operating room to correct the problem.

OB/GYN kept us busy both in their clinic and with their emergency patients.  They had two patients come in at once very sick, with critically low blood pressure.  One was a ruptured live 8-week ectopic pregnancy and the other was a perforated uterus after an abortion.  Both patients were rushed to the operating room with units of blood hanging en route.  And if Dr. Laura had not had enough OB/GYN ultrasound for the week, she went to Bong County to scan there with the residents.  Twins, triplets and more twins…multiples seem to be the theme in Bong!

August 28th: Liberia

teaching sessions

In a single 24-hour period, we made the following diagnosis by point-of-care ultrasound:

• Intussusception in an infant
• Severe pulmonary hypertension in a toddler
• Enormous pericardial effusion in a young child
• Severe tricuspid regurgitation in a young woman with difficulty breathing after childbirth
• Resolving bilateral hydronephrosis in a young child with bladder injury

If the medical terms above leave you squinting at words on the page, suffice it to say that this is an impressive collection of diagnoses. Without the ultrasound, none of them would have been made. Furthermore, all of these findings dramatically changed the course of action for these patients.

The little girl with intussusception (intestines telescoping inside of one another and getting stuck) had been treated for days at another facility for a bacterial infection of her intestines. After the ultrasound, she went to surgery to reduce the intussusception and is now recovering. The child with severe pulmonary hypertension (where the right side of the heart has to work too hard) was started on diuretics to improve his heart function. The boy with the resolving hydronephrosis (fluid in the kidneys) was sent home. And late last night, we used the ultrasound to guide the pericardocentesis (drainage of fluid from around the heart) in the little girl with the pericardial effusion. She will now be started on medications for tuberculosis (the cause of the fluid).

In a setting where lab tests and other forms of imaging are limited by both availability and cost, point-of-care ultrasound is a game-changer. We have used the ultrasound to assess the repair of ruptured bladder with serial abdominal ultrasounds documenting no free fluid (or leak) in the abdomen. We have reassured ourselves with numerous normal ultrasound exams.

Late last week, the residents asked to ultrasound a woman with a complex hospital course with persistent abdominal pain with them. As the residents slid the probe upwards from her bladder to examine her uterus, we found a large fetus outside of it! We quickly moved our probe to evaluate for free fluid in her abdomen and found the tell-tale signs of blood in her abdomen. The woman was immediately wheeled to the operating room where she was found to have a ruptured uterus and a significant internal bleeding. The resident called later that evening to saying the ultrasound had saved her life. She was discharged home early this week.

 

– Alex Vinograd, MD, MSHP, DTM&H

August 15th: Liberia

PURE team in Liberia

Ultrasound training continues in Liberia with Dr. Alex Vinograd working through challenging cases on a daily basis with our resident trainees at Phebe Hospital in Bong County and JFK Hospital in Monrovia. Here is her latest report:

“The last patient I saw this week was a young woman with abdominal pain who reported several months of increasing abdominal distention. On any given Friday afternoon in the United States, I can order dozens and dozens of laboratory and imaging studies. For many of them, I can get results in hours, if not minutes. In this hospital in Liberia, on a Friday afternoon, you can obtain little more than a hemoglobin and a malaria smear. From across the room, it looked like she was in labor.  She moaned and writhed in pain holding her abdomen.  She appeared to be nine-months pregnant – but her pregnancy test was negative. Assuming the problem was free fluid in the abdomen from a liver problem or peritoneal tuberculosis, she had been admitted to internal medicine.  But, when we place the ultrasound probe on her abdomen to investigate, there was no free fluid.  Instead, we discovered a massive cyst measuring 25 centimeters in diameter filling her abdomen! The ultrasound exam was a game changer, resulting in a completely new differential diagnosis, and new plan. Tell any physician about a female patient presenting with severe abdominal pain, a negative pregnancy test, and a large ovarian cyst and top of the differential diagnoses will be ovarian torsion – that was now the case. She was transferred from internal medicine to the operating theater with gynecology.   Findings were indeed consistent with an enormous ovarian cyst that had twisted on it’s pedicle – this had cut off its blood supply which cause her acute abdominal pain. It was removed and the patient is now was recovering well.”

Alex will be continuing our ultrasound training efforts over the next month and will soon be joined in Monrovia by PURE trainer Dr. Laura Diegelmann.

August 2: Monrovia, Liberia

Trainees are happy to bring the scanning table abnormal abdominal fluid Abdominal ultrasoundAnother busy week of scanning has flown by for our ultrasound team in Monrovia! We spend each morning rounding with pediatrics, internal medicine, surgery or obstetrics/gynecology at JFK Hospital. The resident physicians are enthusiastic learners and the cases they present are educational for the ultrasound instructors and trainees. Point-of-care ultrasound during bedside rounds last week led to the diagnoses of traumatic bladder rupture, hemothorax, hemoperitoneum, pneumonia, ventricular thrombus, congestive heart failure, hydronephrosis and abscesses leading to significant changes in management.

One of our most interesting cases this week was a middle-aged man who presented a week prior with abdominal pain and distention with a history of remote fever. On x-ray there was air in the abdomen – free air should generally never be obvious below the diaphragm on x-ray. As he looked overall well at the time, the air was thought to be contained in a liver abscess and he was admitted on IV antibiotics. An ultrasound evaluation with our resident physician team revealed free intra-abdominal air consistent with bowel perforation and a complex fluid concerning a severe infection in his abdomen. A bedside sample of the fluid confirmed our findings – pus inside the abdomen. He was taken to the operating theatre that afternoon to wash out his abdomen. This morning, we found him roaming the wards looking incredibly well.   Another busy week on the wards to come we are sure…

July 22: Zanzibar, Tanzania

During initial meetings in April between PURE, the Minister of Health, and local stakeholders, diagnostic imaging was identified as a major priority of the health system in Zanzibar, a chain of islands of the coast of Tanzania. Now, four months later, Dr. Abiola Fasina, a fellow in emergency ultrasound from the University of Pennsylvania, is in Zanzibar working with PURE, the Zanzibar Ministry of Health and ZADIA, the Zanzibar Diaspora Association. Below is her report:

“Hello from the Spice Islands! So far I’ve visited the main referral hospital on Unguja Island, Mnazi Moja, which is located right near Stone Town. I’m exploring current limitations to ultrasound use here as well as possible future directions for training through discussions with various medical staff members. Last week, I had the opportunity to visit Zanzibar’s second main island of Pemba to assess 5 rural hospitals. It is an exciting time on Pemba Island as both the hospital at Micheweni and Mkoani are to become district hospitals by next year. This means improved access to specialist care and new additions or improvements to their physical space. The theme emerging from my assessment so far is an acute need for ultrasound in the care of obstetric and trauma patients in particular.

This week, I’ll visit the 2 district hospitals here on Unguja Island and then met again with local stakeholders and ministry of health staff. The government of Zanzibar and local staff are really keen on getting this program off the ground and providing improved care and service to their patients.”

PURE and our partners in Zanzibar are seeking funding to execute a locally relevant ultrasound training program by early 2016. Please contact us if you are interested in getting involved!

Mkoani Chake

July 18th, Liberia

Temp & screening in the context of Ebola Raja doing didactics photo 1-8 pedi trainees practicing

Three physicians from the PURE team arrived in Liberia last week launching a longitudinal point-of-care ultrasound training program for all resident physicians. Working with the Liberian College of Physicians and Surgeons and the Academic Consortium Combatting Ebola (ACCEL), PURE is leading this health system strengthening effort to advance the skills of local physicians in the realm of diagnostic and procedural ultrasound capacity at the point-of-care.

On Wednesday, we drove 4 hours from the capital to Bong County where we began working with a group 4 obstetric-gynecology 2nd year residents, 3 pediatric 2nd year residents, and 3 medical officers. Dr. Trish Henwood introduced the concept of point-of-care ultrasound and Dr. Raja Rao followed up with a lecture on physics and knobology. A few minutes into the small-group practical session as we played with depth and gain on the machines, a resident asked Dr. Raja to consult on a puzzling case. There was a pregnant woman on the OB ward who presented with a reported 12-week gestation with abdominal pain and a concerning mass. Dr. Raja helped determine the mass was actually the uterine fundus with a thickened endometrium, and the live 12-week fetus was actually an ectopic pregnancy! The patient’s vital signs were becoming suggestive of early hemorrhagic shock and the FAST ultrasound findings showed new significant free fluid compared with their earlier assessment confirming the diagnosis: life-threatening ruptured ectopic pregnancy. As Dr. Raja returned to the conference room to oversee as the trainees practiced FAST exams on one another, the patient was rushed to the operating room and survived.

The next two days were packed with practice. The OB-GYN residents lined up a series of pregnant patients and took turns scanning and looking over each other’s shoulders to discuss the findings. One woman reported that this baby was bigger than her other babies. The ultrasound finding? → Twins at 35 weeks gestation!
Dr. Trish broke off to oversee a resident scan another pregnant woman with a similar history. The diagnosis? → Triplets at 33 weeks gestation!

The pediatric residents identified a child with 2 months of right leg swelling and a recent refusal to walk. Her right thigh and right knee were swollen without erythema or warmth. The laboratory has no ability to run a complete blood count or inflammatory markers. An x-ray had been scheduled. Her point-of-care ultrasound showed an irregular bone cortex from mid-femur to the metaphysis with fluid surrounding her bone, fluid in her hip joint and fluid in her knee. Large lymph nodes were identified in her groin. The diagnosis? → Concern for septic arthritis of the hip and knee and osteomyelitis of the femur. The next day we obtained her x-ray which showed a moth-eaten femur supporting our findings. The pediatric team has contacted the orthopaedic surgeon to arrange further management.

This coming week we look forward to evaluating the baseline ultrasound skills of all of the first year resident physicians as we launch the training program in Monrovia.
Stay tuned for more updates!
– Dr. Alexandra Vinograd

Dedicated to improving ultrasound education in the developing world