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.
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.
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!
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.
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.
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.
…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!
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.
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!
Week one of this round of intensive ultrasound trainings in Kigali has come to a close as we end the day with a large group from internal medicine. Mid-week we challenged the emergency medicine post-graduate trainees to an observed clinical skills exam in cardiac and thoracic applications as well as the FAST exam for free fluid. We then had 7 of those trainees for a follow-up didactic and practical session on the E-FAST exam. Overall these sessions helped the EM faculty identify exam where we will focus our skills training while PURE team member, Dr. Paul Pageau, remains here for continuity teaching over the next few months.
Thursday we had a large group of very enthusiastic pediatric residents who were eager to learn, and quick to pick up, the basics of ultrasound. Five team members were here to provide lectures on the basics of ultrasound physics, FAST exam, procedural skills, lung ultrasound and an amazing pediatric GI lecture by our radiologist, Dr. Raja Rao. Future PURE team member and 8-year-old son of Dr. Pageau was even willing to have the keen pediatricians ultrasound him to get some smaller sized scanning experience. The week came to a very rainy end today as we were joined in the Simulation and Skills Center by about 18 residents and several of the internal medicine faculty. The largest group of the week was packed with many of the regular lectures and practical sessions, with a highlight being a great cardiac exam and ultrasound lecture by cardiologist and HRH faculty, Dr. Gene Bukhman, in addition to a good review of liver ultrasound by Raja. The PURE team is looking forward to a brief break tomorrow before we begin traveling and gearing up for our training efforts next week.
PURE is back in Rwanda for more busy weeks of ultrasound training for all of the Masters of Medicine and Post-Graduate medical training programs as the academic year transitions. So far this week is off to a great start! Monday was busy teaching OB/GYN residents point-of-care ultrasound exams in a variety of abdominal applications and DVT, after a morning review of ultrasound physics. Yesterday and today we had the pleasure of teaching the anesthesia residents. This very attentive group got exposure to the FAST exam, cardiac and lung ultrasound, ultrasound-guided peripheral and central access, and nerve blocks with a mix of didactic and lots of hands-on practice. This afternoon we will be working with the emergency medicine post-graduates and then onto large groups from pediatrics on Thursday and internal medicine on Friday. All of our trainings this week are taking place on a cadre of Sonosite M-Turbo ultrasound machines that are dedicated for training purposes in the Simulation and Skills Center at CHUK, the University Teaching Hospital of Kigali.
PURE’s President & Co-Founder, Dr. Trish Henwood, is leading the current trainer team. First, we have Dr. Paul Pageau, an ultrasound-trained emergency medicine specialist from the University of Ottawa in Canada. We are excited to have Paul, along with his family, here in Rwanda over the next 3 months to provide ongoing ultrasound teaching and follow-up on behalf of PURE. Dr. Laura Diegelmann from the University of Maryland returns for a second time to assist with the didactic and practical sessions over the next few weeks. Dr. Helen Ouyang, also emergency medicine trained, from Columbia University just arrived to Rwanda for the first time to share her expertise in ultrasound and passion for working in resource-limited environments. Dr. Raja Rao, a member of the PURE Board of Directors, hails from Oregon in the USA and is recently retired from his interventional radiology practice there. Raja has significant experience teaching ultrasound in resource-limited settings and returns to Kigali with us to add his perspective and expertise to the practical applications of ultrasound. Later this week we are happy to have Dr. Colleen Holley, an emergency ultrasound fellow from the University of Maryland, joining the team through late September.
Overall the trainings are off to a great start and we are excited to continue working with our colleagues in the Rwandan Ministry of Health and Faculty of Medicine on a variety of training programs to help further increase ultrasound capacity in Rwanda.
On Tuesday March 11th the PURE team took a trip to the Rwanda Military Hospital to meet with the Clinical Director, Dr. Eugene Ngoga, to discuss plans for training more students, interns, resident physicians and general practitioners in clinical ultrasound.
In addition to time spent in the ED and ICU, we visited the OB wards where Dr. Ngoga works and teaches. We were lucky enough to come across a group of medical students working with the ScanTrainer, a transvaginal ultrasound simulator used for medical education. We got great feedback from the students on this teaching tool and they are enjoying the afternoon times Dr. Ngoga has put aside for this learning modality during their OB-GYN rotation.
A special thanks to Dr. Ngoga for his focus on medical education and continued support of PURE’s efforts, and to MedaPhor for the loan of this great product!
On March 7th, PURE members Drs. Trish Henwood, Laura Diegelmann and Cindy Hsu, working in conjunction with some of Rwanda’s Internal Medicine residency leaders Drs. Tim Walker, Gene Bukhman and Yuki Aoyagi conducted a full-day ultrasound session for 15 internal medicine residents at the Centre Hospitalier Universitarie de Kigali’s (CHUK) Simulation Center. The team lectured on introduction to ultrasound physics, cardiac ultrasound, DVT evaluation, and abdominal ultrasound (focusing on FAST, with a brief overview of biliary, renal/bladder). The didactics were interspersed with practical sessions for the trainees to familiarize themselves with knobology as well as perform the aforementioned exams on each other. The trainees asked plenty excellent questions throughout the day, picked up the techniques quickly and left eager to work with their attendings in applying their newly acquired skills during their future clinical encounters.
Stay tuned for updates on PURE’s upcoming training sessions and
clinical scanning shifts with the CHUK emergency physicians in the
weeks to come!
Dedicated to improving ultrasound education in the developing world