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

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!

 

Dedicated to improving ultrasound education in the developing world