Mbarara, Uganda, September 20, 2016

 

The PURE Uganda team led by Trish Henwood & Katie O’Brien has been quite busy hosting various ultrasound teaching conferences over the last week! Last Thursday and Friday we hosted day-long teaching sessions including ultrasound physics, how to use the machine, and the extended Focused Assessment with Sonography in Trauma (eFAST). Trainees included MRRH/MUST anesthesia and surgery residents, Emergency Care Providers (ECPs) from Global Emergency Care Collaborative (GECC) and our SEED Global Health colleagues working at MRRH/MUST for the year. The enthusiasm of the learners was infectious, and we beamed seeing surgical residents explain ultrasound concepts to each other and fist-bump as a sign of confirmed understanding!

 

Today, we finished our formal sessions with the leading help of Dr. Godfrey, faculty with the Department of Ob/Gyn, and a strong representation from our Obstetrics and Gynecology colleagues – both residents and midwives. There was a lot to cover and it was a long day but everyone gained a lot from the session and went away with a lot to practice. Classroom teaching is over for now but the real fun – hands-on, bedside clinical teaching – is continuing.

 

Tomorrow, Dr. Kate O’Brien will be heading to Nyakabale to perform hands-on training with the GECC ECPs while Charlotte Skorpen (an ultrasound trained medical student in her 6th year originally from Norway), and I (Dr. Sally Graglia) will be doing follow-up bedside teaching with the Obs&Gyn residents. Together we will be working with the ECPs in Masaka on Thursday, then looking forward to continuing bedside teaching in Mbarara next week. Until next time!

Dr. Sally Graglia, MD MPH
Emergency Ultrasound Fellow
Massachusetts General Hospital

September 11-17th, 2016, Kigali, Rwanda

The PURE Rwanda team is enjoying the opportunity to help kick-off the academic year in Kigali! Dr. Rachel Zang (senior Penn EM resident) has been here working hard over the past few weeks with the Rwanda EM faculty to get things ready for the arrival of Dr. Tu Nguyen and myself from the University of Maryland in order to lead the ultrasound portion of EM intern boot camp!

Tu kicked off the ultrasound course on Tuesday with the intro lecture followed by the FAST exam by Rachel. The new intern class caught on quickly to the basic skills on day one. Part of the afternoon was spent in the ED with the senior residents. Pneumothorax and other lung pathology was the day’s theme, foreshadowing what the interns learned on day 2. I assured them that they would be pulmonary ultrasound experts in no time! Tu tackled the cardiac exam and we all look forward to seeing how much the interns learn over the next few weeks. A new practice this year involved the senior EM residents joining us to help lead the practical sessions. Together we were able to help advance their own teaching skills and knowledge while they did a great job of educating the interns on the basics.

The week finished with some amazing scans by the senior residents in the ED with findings including their first pelvic kidney, a cardiac myxoma, pneumonia, gallstones and a bowel diameter over 16cm in a patient with concern for obstruction – the surgeons took it from there! Our team is looking forward to lots more bedside scanning and teaching with the Rwandan EM residents next week!

– Dr. Laura Diegelmann

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

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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…

Dedicated to improving ultrasound education in the developing world