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