Uganda, Ultrasound, and low resource emergency medicine

Having traveled and worked in under-resourced settings before, I thought I had some idea of the type of clinical situations I would be encountering while teaching in Masaka, Uganda with the Global Emergency Care (GEC) program. However, during my three weeks at the Masaka Regional Referral Hospital, I was continually amazed by the breadth and acuity of conditions seen by the medical officers (MO’s) and emergency care practitioners (ECPs) in the Accident & Emergency (A&E) department. They managed some of the sickest patients I have ever seen with foley catheters for chest tubes, only four oxygen wall regulators, one intermittently functioning defibrillator, and minimal IV medications. It was exciting to watch the ECPs utilize clinical and ultrasound knowledge acquired through their diploma program to direct and improve patient care.

Take, for example, the 20-year-old man who presented with proximal right forearm swelling. He had been stabbed in his forearm, just below the elbow, at the beginning of January (over two months ago). He had presented to the hospital immediately after the injury, and had the wound closed with stitches at that time. Sometime in the next two months, he started to notice right forearm swelling and pain. He had no fevers, and there was no obvious infection around the original wound. The swelling bothered him enough in late March for him to present for medical attention. The first medical officer to evaluate him was concerned that he had an abscess under his skin, so sent the patient to the A&E for them to cut open his forearm.

When first evaluated by one of the senior ECP graduates named Alfunsi, he recognized that something wasn’t right about this story. Alfunsi elected to put his ultrasound skills to use.

Ying yang.jpeg

Upon placing the ultrasound probe on the patient’s forearm, he immediately realized this was not an abscess; the fluid collection didn’t look right. When color flow was placed on the large, round fluid collection, the fluid was pulsing! This was, in fact, either a pseudoaneurysm or aneurysm of the radial artery with a fistula between the cephalic vein and radial artery. In essence, the knife wound in January had poked a hole in the artery in the patient’s upper forearm and connected the artery to the nearby vein. Every time the artery pulsed, it had been pushing blood into the vein and the surrounding soft tissue. These ultrasound findings were reinforced by the fact that the patient had only a very faint pulse at his wrist near his right thumb (the distal radial artery), but a very strong pulse in his left wrist. If Alfunsi had cut open this wound, it would have bled all over the room, and the patient could even have lost his arm. Instead of antibiotics or cutting open the swelling with a scalpel, this patient needed a vascular surgeon to repair the artery and vein.

Alfunsi and the other ECPs took the initiative to call over the intern physician to explain the case. After reviewing the ultrasound findings with the ECPs, the intern agreed with them; this patient needed to be referred to a vascular surgeon. Since there are no vascular surgeons in Masaka (the hospital, in fact, does not even have a CT scanner, let alone sub-specialists), the patient was referred to a surgeon in Kampala. I realized that by spending a few extra minutes evaluating this patient with bedside ultrasound, Alfunsi may have saved this man’s arm.

This was one of many cases I witnessed in the Masaka A&E where ECP clinical knowledge and ultrasound skill greatly improved patient care and outcomes. It is incredibly powerful and fulfilling to watch expertise you have shared with ECP learners be directly translated into clinical care. In my experience, this information-exchange is the most impactful in incredibly under-resourced locations like Masaka, Uganda. Even small changes in knowledge base or imaging availability (i.e. having a bedside ultrasound available in the A&E for ECPs to use) has a huge impact on patient care, community health and system-wide practice. I am so grateful to the staff at the Masaka Regional Referral Hospital for sharing their enthusiasm and ingenuity with me during my time in Masaka, and so excited about the work that GEC is doing to help empower the medical community in Uganda.

Dr. Leigha Winters

Sonography for Beriberi. #POCUS for severe vitamin deficiency coming soon.

Ramping up for our fall trip to southeast Asia.  This year we are excited to start work on a project in Laos where we will be evaluating pediatric patients with severe vitamin B1 deficiency.  Also, commonly called Beriberi.  Did you know you can diagnose and manage Beriberi with ultrasound?  It likely has not crossed your mind unless you have worked in regions with severe vitamin deficiencies, but the literature is out there.  Some anyway.  Surprisingly the spectrum of vitamin B1 deficiency is not well characterized.  We worked over the past year to develop an exam protocol looking at infant brains and hearts for signs of beriberi as part of a Gates Foundation Grant.  Our experience from Laos showed us that due to the mother’s restrictive diets post-partum and cultural food preparation practices (rice washing) infants can present in florid heart failure due to beriberi.  As part of their manage in these endemic regions Vitamin B1 is given intramuscularly and rapid clinical improvement typical ensues.

Echo demonstrates global reduced systolic function.  Cranial has symmetric hyperechoic changes near the putamen, caudate nucleus.

The current plan is to train local Lao sonography technicians to do these exams and patients will be identified and tracked over time.  There will be a two-week training, remote quality assurance, and local oversight by a Lao pediatric cardiologist.  Likely re-visit in 6 months.

After the Lao training, we plan to move onto Hanoi, Vietnam where we will be training the PICU and ED physicians at one of the country’s largest pediatric hospitals in POCUS.  Since we were told they have not had previous training, we will start with the basics and move on to cover resuscitation, echo, lung, FAST, and procedural guidance.  There is an annual EM and critical care conference in Vietnam (VSEM) that runs a POCUS workshop that I know many attend (since I helped teach the course in 2015).

It is looking like fall is all pediatrics all the time!  Pictures to come.

Nepal Trip to Friends of Shanta Bhawan Clinic in Boudha Kathmandu. #pocus #nepal #meded #kathmandu #globalhealth @ucdavisem @theucdavisguf @ultrasoundstuff

Friends of Shanta Bhawan is an outpatient clinic in the heart of the Kathmandu Bhouda district, which is primarily populated by Buddhist Tibetans.  It is a non-profit clinic that is supported by the NGO Hands in Hands. There are currently 3 full time physicians who work Sunday-Friday 9-3pm.  They see a moderate volume of pediatric and adult patients.  They run vaccination, family planning, and antenatal clinics as well as manage acute and chronic non-emergent medical problems.  Our visit was to support the clinics mission of serving the Tibetan marginalized population and to expand their ultrasound knowledge and practice.  For four weeks, we focused on building skills in abdominal, pelvic, pulmonary ultrasound as well as echocardiography.  The have a dated Toshiba machine with one curvilinear low frequency probe that is working fine currently, but need updated equipment and a wider probe selection.

They also do free health camps at the clinic and around Kathmandu therefore a portable ultrasound device would greatly benefit the clinic and population.  Two surprises during the trip was that the physicians were interested in prostate ultrasound, which we could only teach trans-abdominally. The other was that despite charging little for services, the clinic is financially reliant on the ultrasound revenue. Therefore, updating the equipment and having a backup system is a necessary future project.  The clinic recently created a relationship for referring patients to Kist University Hospital.

This site is a great clinic for multidisciplinary collaboration as you can help if you are FM, IM, peds, OB/GYN, radiology, or EM.  They are happy to host residents and students, but would ask a fee to host medical students. Kathmandu is a great place to visit and is in high need of medical support and development.

Laos 2017

Practicing in urban southeast Asia a seven-year-old girl presents after several weeks of progressive left leg pain and inability to walk.  Over a month ago the girl had a fever.  Her father was concerned and went to the local pharmacy.  The pharmacy provided the father with an intramuscular injectable anti-pyretic.  The father injected the medicine into her upper left leg.

The patient presented with a fever and was ill appearing.  She was unable to range her left hip or walk due to pain.  There was no apparent cellulitis or subcutaneous abscess.  She was admitted for intravenous antibiotics and fluids.  The admitting physicians were most concerned about a septic joint, but the diagnosis could also be pyomyositis (a common diagnosis in this region).  A radiograph of the left hip and knee were done and interpreted as unremarkable.  All other imaging was unavailable.  A surgical consultation was ordered, but without imaging the surgeon was not willing to attempt any intervention.

Upon our arrival to the hospital we performed a musculoskeletal POCUS of the bilateral hips.  POCUS of the hip joint is best accomplished with the high frequency or linear probe in the pediatric patient, but low frequency probes may be used if the linear probe is unavailable.  To evaluate the hip for an effusion with POCUS begin just medial to the ASIS, in a slightly oblique-sagittal plane.  This will give you a longitudinal view of the hip joint.  Identify the femoral head and acetabulum, followed by the femoral neck inferiorly.  Hip effusions typically appear as an anechoic collection at the femoral head that extends to the femoral neck.  You may also visualize effusions from the lateral position of the patient.

hip case anatomy with fluid collection copy

A collection that is not acute may not appear purely anechoic.  However, there ought to be asymmetry when compared to the contralateral hip.

hip case dual screen copy

A large mass like collection was identified in this patient.  It was initially assumed to be a large joint effusion, but on further evaluation it was less clear if the collection was within the joint capsule or just outside the capsule.  I believed the collection was just outside the joint and likely pyomyositis.  A radiologist at the bedside believed it was most likely within the hip joint.

hip case long fluid collection copyhip case collection in short axis copy

Surgery was re-consulted post imaging and they recommended ultrasound guided diagnostic fluid aspiration.

For this procedure, it is important to identify your landmarks and then take note of nearby blood vessels and nerves.  I mark the location of the vessels so I am sure to avoid them during the procedure.  We used an anterior approach, because the fluid collection was most accessible from this view.  Using the high frequency probe, sterile technique, follow a large gauge (18) spinal needle in-plane (longitudinally) and aspirate fluid.  In this case, we used procedural sedation.

hip case measure depth for procedure copyhip case needle aspiration copy

The procedure was completed without issue, but we were unable to aspirate any fluid.  The reason is unknown, but likely due to the chronic nature of the infection and the now near solid consistency of the collection.

Without aspiration of fluid the surgeon was not willing to intervene.  Another week went by without significant clinical improvement before the surgeon took her to the operating theater.  The surgeon identified a large collection of purulent fluid just anterior to the left hip joint, but not within the joint space.  It was incised, drained, and irrigated.  The patient’s clinical condition improved on antibiotics.  Her fevers resolved and she appears well now.  Her ambulation improved some and she is using crutches.  Unfortunetaly, at the time of this posting her ESR level remained above 100 and a repeat ultrasound showed re-accumulation of the fluid collection.  More to come….

Laos Friends Hospital for Children (LFHC) is a newly built (about 5 years old now) pediatric hospital in Laung Prabang, Laos.  LFHC was built as a co-venture between the NGO Friends without Borders and the Laos government.  It has a busy outpatient clinic, inpatient ward, small emergency department, small NICU, and a single operating theater.  The model that has been created is to utilize a constant team of foreign trained physicians to work with and train young Lao physicians.  The administrative team does a fantastic job recruiting and bringing in a constantly rotating team of fantastic people from all over the world.  They have fostered an educational environment where there is constant learning and teaching going on.  Formal teaching goes on once a week and Lao physicians also spend dedicated time learning English.  For rotating faculty and residents, the clinical and educational experience is superb.  Our focus during our first trip was to assess the site, teach ultrasound, and help out in the ED.  We now have goals and expectations for POCUS training moving forward and have an established site for trainees and faculty to work and gain valuable pediatric experience.  Our global health and ultrasound fellow will be traveling there once or twice this year and we have at least one senior resident that will do their global health rotation at this hospital.

If you are going as a resident, be prepared to function as a senior resident there as well.  Some big reasons to work and learn at this site is that the diversity of pathology is fantastic, the infectious disease profile is likely very different than what you have seen before, and it is a fun place to work!  The people are great, welcoming and the city of Laung Prabang is a wonderful, safe place to visit.

Belize 2018

Another EM development trip successfully completed to Belize.  As part of a team, which includes MCW, Baylor, and Brown we have worked to strengthen emergency care in Belize by training physicians, nurses, and EMTs.  The program has progressed and we are now looking towards emergency medicine board examination and specialty recognition.  This trip we put the physician team at Karl Heusner Memorial Hospital (KHMH) through a 2-week board review course.  I also spent time (as I always do) teaching POCUS at KHMH and western regional hospital in Belmopan.  I continue to foster their ultrasound skills, ultrasound champions and seek better training and equipment for this group.

IMG_4608Belize and KHMH is an excellent opportunity for faculty, fellows and senior residents to be involved in low resource environment care and emergency medicine development.  It is also a great location to practice your medical Spanish.  The official language of Belize is English, but you will find that most people speak Spanish first, English second.  Advantages of this site are short, cheap flights, true emergency medicine being done, high need for education, welcoming people, nice weather, and plentiful recreational opportunities.  The capabilities of the hospital include a 25 bed ED, subspecialty care, a small ICU, and occasional CT scanning (when functioning).  There are opportunities to teach at the hospital, other regional hospitals, and the Belize Emergency Response Team (BERT).

Uganda 2018

One week into our trip to Uganda, we take to the wards with our training group for some hands-on POCUS practice.  At Masaka Regional Referral Hospital, in the middle of the male ward there is a man dying.  He can’t be more than 35 years old, in a partial tripod, with his hands on the thin rusty metal bed frame, knees to his chest, and gasping for air.  I lead our group to the bedside as my fellow selects the appropriate transducer and power ups the SonoSite.  I ask our Ugandan trainee, a burgeoning Emergency Care Practitioner, if she could please tell me why this patient is dying.  We get the patient positioned and she looks at the lungs: no pneumothorax, no B lines.  She moves onto the heart and with some guidance and acquires a perfect parasternal long view.  What do you think?  I ask her.  There is pericardial fluid, she says.  Not only that, normal left ventricular function with pericardial tamponade.  Now we must tell someone.  Luckily at that moment the medical team is rounding in the ward.  They have the patient’s chest X-ray in hand, which shows “cardiomegaly” with clear lung fields.  They had therefore been treating the patient for heart failure with diuretics.  A bit of debate ensues, but to see is to believe and once we show the team the echo surgery is consulted.  One of our learners assists the surgeon for a bedside ultrasound guided pericardiocentesis.  The patient is then taken to the operating theater.  In this region, there is a high likelihood the patient has HIV and tuberculosis.  Diagnostics are limited and he can easily be septic and anemic as malaria is also endemic.  The patient transiently improves, but later dies.  Our trainees learned the value of POCUS that day, the power it has in diagnosis and management.  Perhaps next time a similar patient can be identified early and have a better outcome.

Photo Dec 10

During our second week, a 20-year-old female presents for acute abdominal pain to the accident and emergency ward.  POCUS shows a large amount of free fluid in her abdomen.  We evaluate her pelvis trans-abdominally, but cannot appreciate an obvious ectopic pregnancy.  This remains our top diagnostic concern.  Unfortunately, there are no pregnancy tests available at the hospital and the surgeon will not take her to the theater without one.  So, my fellow and I run the quarter mile into town to buy a pregnancy test.  We return and the patient is positive.  She is taken to the operating theater for a ruptured ectopic pregnancy.  The next day we see her on the female ward, where she is recovering nicely.  She sees our group and gives us a brilliant smile.

20161216_124001In Uganda we work with Global Emergency Care who runs a train the trainer program, elevated nurses to Emergency Care Practitioners.  Is a great site for residents, fellows and faculty to be part of this teaching program and impact care in east Africa.  The role for visitors is primarily educational and as mentors.  Considerable time is spent in the clinical setting, but not in a primary clinical role.

Photo Dec 15

You can visit Global Emergency Care at: Global Emergency Care