Friday, March 24, 2017

Ultrasound in the Operating Theater - Botswana


David Bartels, MD
Resident in the Department of Anesthesiology, Critical Care and Pain Medicine at Massachusetts General Hospital
PGY4


Ultrasound in the Operating Theater - Botswana
 
Arriving in Botswana, Devan and I were excited to see peripheral nerve blocks and central access procedures performed under landmark technique. After a certain generation of trainees, these landmark-based techniques are a lost art among American anesthesia residents, as we have “grown up” in the age of ultrasound. That being said, ultrasound use in the USA is considered standard of care for many good reasons, and the potential for ultrasound use in the developing setting is huge. Ultrasound is safe, non-invasive, and fast to use. It serves as a diagnostic and procedural aid.  It is performed by the clinician at the patient’s bedside in real time. It is recommended for use in high-risk vascular access procedures (e.g internal jugular central line placement) and is beneficial for regional blocks by reducing risk of local anesthetic systemic toxicity, increasing regional block success, reducing time to complete the block, and reducing the effective dose of medication. Performing regional nerve blocks and vascular access procedures under ultrasound guidance requires two components: (1) availability of an ultrasound machine and (2) training on how to use ultrasound. Princess Marina Hospital is fortunate to have a modern ultrasound machine that is shared among departments and is housed in the intensive care unit. Yet, many of the staff have not been trained in ultrasound use.

During our time in Botswana, we have provided ultrasound training to medical students, medical officers, and staff using the ultrasound from Princess Marina Hospital.  This training has spanned the spectrum from learning the basics of ultrasound physics to visualizing anatomy on volunteers. In addition, we have covered the basic “knobology” and handling of the Princess Marina Hospital ultrasound such that staff anesthetists are more comfortable in procuring and optimizing images. We have also discussed the vocabulary used to describe ultrasound images (e.g. “hyperechoic”), such that we are able to communicate clearly with each other. It is our hope that with this foundation, further education can occur either via self-practice, further workshops, and guidance via telemedicine.

Devan teaching basic ultrasound use to staff and students at Princess Marina Hospital.
In addition to this training, we have trialed the use of the Accuro ultrasound device, which was generously loaned to us for the month by Rivanna. The device is designed to obtain neuraxial ultrasound images for spinal and epidural placement and estimates the distance to the epidural space. While the device was not used clinically, we did use it as a teaching tool on volunteers to demonstrate neuraxial anatomy, which was an incredible aid.

Two medical officers practice using the Accuro neuraxial ultrasound device.

This past week, we provided a dedicated ultrasound workshop to Princess Marina Hospital operating room staff during their weekly academic rounds. After Devan and I reviewed ultrasound basics and answered questions, we assisted staff anesthetists in practicing with the ultrasound and provided an “in-service” training session throughout the morning. This practice consisted of the basics on how to handle the probe and operate the machine. More advanced staff practiced needle visualization using expired needles donated by MGH colleagues and hunks of polony (a compressed meat similar to bologna). This practical session was a huge success and a lot of fun. More importantly, our Princess Marina Hospital colleagues recognized the value of ultrasound use in their practice and are eager to learn more. This will be the next challenge – to ensure that our training is part of a sustainable educational endeavor.

David listens while leading a Friday morning departmental discussion about basics of ultrasound. A portrait of Botswana’s president, Ian Khama, hangs in the background.

Princess Marina Hospital staff anesthesiologists and medical officers practicing ultrasound visualization of the internal jugular vein on a colleague during our ultrasound workshop.

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