Thursday, October 30, 2014

Point-of-Care Ultrasound Training for Emergency Medicine Residents in Kigali Rwanda

October 30, 2014

I am so grateful to have had the opportunity to join the PURE Team here in Rwanda and thank the Center of Expertise in Global and Humanitarian Health for making it happen.  PURE stands for Point-of -Care Ultrasound in Resource limited Environments and was created by a rock star former Harvard Emergency Medicine resident Dr. Henwood.  When Dr. Henwood gave a presentation on the impact of Ultrasound in resource limited settings her senior year, I knew that I wanted to not only perfect my ultrasound skills, but to also provide a useful skill to the practitioner abroad who sometimes may feel helpless when CT or Xray is not readily available.

Day 1
I survived a long trip to Kigali, Rwanda.  The view from the plane was amazing.  The landscape reminded me of my days as a child living in Swaziland.  I was picked up from the airport by one of the team members and given a short tour of the city before going home and crashing.  The people were wonderful and I even learnt a few greetings in the local language.

Day 2  We packed up the rental car to go to a district hospital about 2.5 hours away to give a training on Cardiac ultrasounds, FAST, and DVT ultrasound.  We drove up a windy road on a mountain ( mountains are very common here) where my heart literally wanted to jump out of my chest.  The view was amazing.

Unfortunately, the car broke down some where near the top of the mountain.  Within 30 minutes we had the local people call for the local mechanic.  The mechanic came on bike from Lord knows where and he diagnosed our car with an "engine problem" and called for the local tow truck to tow the car back to Kigali.

We paid about 300 US dollars to be taken back to Kigali Rwanda and to have the car towed-my pockets hurt still. It ended up being quite the experience, but somehow we had a wonderful day.  We met new people, saw a new place and broke bread together in the car.
After working in a few places in Sub-Saharan Africa one must be super flexible and adaptable, things happen and you must make the most of it.  I honestly had no complaints about this day.

Day 3
Okay finally work!!  We arrived at the University teaching hospital of Kigali at 8 am.  Our work is performed in the emergency and accident ward mostly, but other internal medicine, surgical and pediatric wards have requested to have scanning sessions for their residents.
 This ward serves a slightly different purpose than the emergency room in the US.  Most patients present from referring district hospitals and this can even be a matter of several days before arriving here.  I was told the role of the ED, is changing though with new emergency residents training in the hospital.  Our job is to teach and help facilitate scans with them and internal medicine, and surgical residents.  We in no way are here to take any role in patient care.

This day was busy, but apparently it gets more busy than this.  We had a number of scans in the morning. For example, we performed an ultrasound on pt who had known cardiomyopathy who presented to the hospital with shortness of breath.

The staff only had an xray from 1 month ago that they continued to refer to the size of the pt's heart.  For whatever reason, xray could not be performed that day.  We had the residents grab the US machine and look at the pt's lungs and heart.  He had bilateral pleural effusions, and diffuse B-lines likely representing interstitial edema.  His heart was globally dilated and had extremely reduced function.  The residents performed the scans and proceeded to treat the pt for a CHF exacerbation.

 We also had a trauma come in from the scene with GCS of 3.  One of the stellar training Emergency residents, ran the trauma.  A-B-C's initiated.  Pt airway was secured with ETT, He had a flail chest and decreased Breath sounds on the right and had a chest tube placed, and he was hypotensive and bradycardic.  His Pelvis was unstable.  The Emergency resident immediately called out for the US.  This was not typical in the past as part of the initial trauma evaluation, but the residents who are so excited about ultrasound have been incorporating it in most trauma pt's.  The FAST was positive lets go to the OR??  or pressures were still in the 60s even with resuscitation. Blood was not readily available. Typically this would result in immediate OR intervention in the US, but the team felt that his head injury was too severe, and his quality of life would have been poor...watching resuscitation efforts/interventions stopped in this pt was a bit unsettling.
 I have been trying to understand the scenario from the Rwandan physicians point of view.  A part of me understands, but still a very difficult pill to swallow.

Until next time...      

~Phindile Erika Chowa,MD
 PGY 3
Emergency Medicine Resident, BWH/MGH