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.

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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

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.

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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.

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You can visit Global Emergency Care at: Global Emergency Care