Clinical Use of Ultrasound at a High Altitude Clinic in Nepal

Bryan Jarrett, M.D. 

Wilderness Medicine Fellow, 

Massachusetts General Hospital Department of Emergency Medicine

PGY4
06/29/2019

Performing a right upper quadrant ultrasound to evaluate for
biliary pathology 

Bedside ultrasound in the emergency department has become a standard supplement to traditional imaging such as x-rays and CT. It is now becoming a primary imaging modality when these more traditional methods are unavailable, especially as we realize the breadth of pathologies ultrasound can diagnose. I recently returned from three months working at a clinic in a remote region of Nepal run by the Himalayan Rescue Association. Pheriche is a small town which sits at approximately 14,000 ft altitude on the trek into the Khumbu valley to Everest Base Camp, and sees approximately 600 to 800 patients each Spring and Fall season. The closest small hospital is in Kunde, a town north of Namche approximately one or two day’s walk away, and has x-ray and ultrasound capabilities. The closest CT scanner is in Kathmandu, a few hours by helicopter or 4 days of hiking and a plane flight away.

I had the privilege of bringing along a Sonosite M Turbo ultrasound provided by their global health division as well as the new ultra-portable Butterfly IQ handheld ultrasound. Through the use of these ultrasounds, I was able to greatly improve clinical care and diagnostic certainty in this remote clinic without access to other imaging modalities.

Lung ultrasound is a very sensitive modality
to detect interstitial pulmonary, such as that
seen in high altitude pulmonary edema (HAPE)

Over the course of the spring 2019 season I performed 83 clinical ultrasounds on 75 patients, which represented 14.4% of our total number of patients. Thirteen of these ultrasounds changed management, 2 improved procedures, and 48 improved diagnostic certainty by providing a useful positive or negative result. The most common ultrasounds performed were pulmonary or lung studies, as more than 30 percent of our patients had respiratory tract infections. Other common modalities included cardiac echocardiograms, obstetric, musculoskeletal, and abdominal ultrasound. As an advocate for training in and access to this incredibly useful diagnostic tool, it was amazing to observe its benefits in a remote environment where it really shines.

Patient with peritonsillar abscess receiving nebulized
lidocaine before drainage guided by ultrasound imaging
before and afterwards. 

One interesting case in which ultrasound proved useful was in a young man who came in with unilateral throat pain. He had what clinically appeared to be a peritonsillar abscess which usually requires either needle aspiration or incision and drainage. The major risk of this procedure is damage to the carotid artery which lies behind the tonsils, sometimes perilously close within a centimeter or two. Thanks to the small linear probe covered in a sterile glove, we were able to visualize the abscess as well as the carotid, and assure that our drainage would stay well away from this critical vessel. Granted, an experience ear, nose, and throat surgeon would usually do this without ultrasound guidance, but they would also have the close back-up of a nearby operating room if anything were to go wrong, a contingency we did not have. Ultrasound in this case made this procedure much safer for the patient and much more comfortable for the providers, and we were able to confirm afterwards with repeat imaging that we had removed as much as possible from the abscess. He felt significantly better after draining 17 cc of purulent material and happily continued towards Everest Base Camp the following day.