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 excellent...now lets go to the OR??  or not...pt 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

Healthcare for All at Hospital San Carlos, Altamirano, Chiapas, Mexico

With the incredible nuns of Hospital San Carlos.

The evening prior to my departure from Altamirano, the Hospital San Carlos nuns invited me to join them for dinner in their community.  As I mentioned in my prior entry, they are a truly incredible group of women.  Each has unique and important responsibilities in the daily functions of the hospital.  Among them include: Sor Rosario, determined hospital director and fearless leader; Sor Edith, wise clinical supervisor and xray technician; Sor Genoveva, director of nursing and nursing education; Sor Paz, pharmacist; Sor Consuelo, near to my heart, head pediatric nurse; Sor Rosaura, head medicine nurse; and Sor Anita, the most senior of the group, tireless nurse anesthetist.  Though each came to Catholic sisterhood through distinct paths, they all share a deeply religious and loving dedication to the poor and marginalized.  A story they shared that evening highlights the irreplaceable role that they and the Hospital play in providing care to so many families throughout Chiapas amidst a sea of barriers:

During a weekend when I had taken a respite to visit the Mayan ruins in Palenque, a gravely ill five year old girl was carried through the doors of the hospital by her parents in the middle of the night.  She was in severe respiratory distress, with a fever, and a concerning murmur, likely decompensating from pneumonia superimposed on a previously undiagnosed congenital heart disease.  Francisco, one of the several new physicians spending his year of social service at the Hospital, immediately called Carlos, an outstanding family medicine physician from Spain who has served as the hospital pediatrician for several years. The patient was rapidly stabilized and survived the 3-4 hour long journey to the pediatric subspecialty hospital in Tuxtla Gutierrez, where she was intubated and placed on a ventilator. Francisco formed a special bond with the family, who, like him, spoke the indigenous language of Tzotzil.  Later the following week, he received a phone call from the parents, informing him that their daughter had died after several days of medical care. They had been profoundly impacted and upset by a question that a Tuxtla provider had asked them, “Why did you take so long to bring your daughter to the hospital?”  Perhaps a sign of a provider having trouble coping with the injustice of losing a young life, or perhaps willful ignorance with regards to daily injustices, including poverty and discrimination, faced by the indigenous communities of Chiapas.

Hospital San Carlos serves as a safe, accessible, and culturally sensitive and acceptable provider of inpatient, outpatient, medical, surgical, pediatric, and OB/GYN care for indigenous as well as autonomous communities throughout much of the state of Chiapas.  Of course, resources are limited.  Plain films and basic labs (which do not include cultures) are available during the day as well as at night in the case of emergencies. Bedside ultrasound skills are acquired by some of the physicians over time.  Outpatient subspecialty referrals can be challenging, whether due to lack of patient resources or long wait lists.  Inpatient transfers, such as for neonates who may need CPAP or intubation, are at times refused by the referral hospital due to lack of beds. 

One segment of the infant and toddler's unit.

Caring for patients in both the inpatient and outpatient pediatric units was truly an excellent clinical experience.  In addition to a handful of newborns, we typically had somewhere between 3 and 7 inpatient pediatric patients.  Admission diagnosis were reflective of two the top five killers of children under five globally, acute respiratory tract infection and acute diarrheal illness.  Probably about a third of infants and toddlers were admitted with bronchiolitis, pneumonia, and a surprisingly high proportion of bronchodilator-responsive bronchospasm, perhaps secondary to indoor air pollution from firewood use.  Another third were admitted with dehydration in the setting of viral gastroenteritis, dysentery, and parasitosis.  These diagnoses certainly have parallels with those that most commonly lead to admission to MGHfC; however, the superimposed stunting and/or wasting among most of the patients clearly demonstrated how chronic and acute malnutrition might contribute to 50% of under-five mortality around the world. 

I learned a number of infectious disease-related clinical pearls during my month: one should assume that all children with severe acute malnutrition have a severe bacterial infection whether or not they have signs or symptoms such as fever; iron repletion for anemia should be deferred until treatment of bacterial infections (e.g. infectious enteritis, see: BMJ 2002;325:1142) has been completed, as there is a theoretical risk of worsened infection; congenital tuberculosis exists (see: N Engl J Med 1994; 330:1051-1054); and the management of fever without a source in well-appearing newborns/infants in the absence of culture data can rely significantly on clinical suspicion. 

Abnormal L5

The remaining one third of admissions encompassed an interesting mix of subspecialty issues. These included: a 12 year old boy with anasarca, ascities, pericardial effusion, and pleural effusions secondary to nephrotic syndrome; a 3 year old girl with >50% partial and full thickness second degree scald burns, one week out from injury, who was transferred AMA from government hospital; a 7 month old boy with tachypnea since birth and failure to thrive, without murmur, but certainly with a yet undetermined congenital heart defect, admitted with worsened respiratory distress; a 3 month old girl with severe stunting, presenting with vomiting since birth, found to have hemoglobin of 4 and guaiac positive stools; an 18 year old boy admitted after intentional ingestion of Gramaxone (aka Paraquat), an almost universally fatal herbicide without effective treatment nor antidote; and a full term, newborn boy with perinatal asphyxia, low apgars, who developed clinical seizures on day two of life, requiring phenobarbital.  I also encountered a good deal of developmental delay, including a 2 year old boy who presented to clinical with a URI and who apparently could not walk, stand, nor really sit appropriately.  He had bilateral ankle clonus, lower extremity spasticity, bilateral Babinski, and these apparent findings on physical exam and plain film:

Violaceous mass over lower lumbar spine.

Hospital de Especialidades Pediatricas - Tuxtla, Gutierrez

I was frequently left with the desire to teleconsult my MGHfC attendings and fellows and, in fact, did speak with one of our wonderful cardiologists, Dr. Manuella Lahoud-Rahme regarding one of our CHD patients.  Wait times for consultations with subspecialists at Hospital de Especialidades Pediatricas are often prolonged, and the prospect of enduring the costs and opportunity costs of travel make the trip all the way to Tuxtla Gutierrez prohibitively expensive for many families.  Performing an echocardiogram while Dr. Lahoud-Rahme watches via Skype, is just one example of the potential for telemedicine to advance access to subspecialty pediatric care at Hospital San Carlos.

Helping Babies Breathe - Workshop 1

In addition to the clinical and community-oriented aspects to my trip, I spent some time working in the realm of formal medical education and quality improvement.  I gave a chalk-talk on a variety of neonatal health issues for the physicians during one of the biweekly morning conferences.  This was perhaps more of a learning experience for me, as my audience helped me grasp the many adaptations necessary to take care of newborns in a low resource setting. Continuing with the theme of neonatal health, Dr. Jennifer Kasper and I prepared an abbreviated Helping Babies Breathe^© training for nurses, nursing students, and auxiliary staff at Hospital San Carlos, in collaboration with Sor Genoveva. 

Nursing students at their capping ceremony.

There were 42 participants who attended one of two, two-hour sessions that focused on the Golden Minute of life and practicing scenarios with NeoNatalie newborn mannequins. About 3 weeks later, I was able to schedule a follow-up refresher session, and while this landed at the tail end of vacation week for the nursing students, 31 learners participated in the workshop, including 10 new participants.  While I had intended to perform OSCEs to evaluate effectiveness of the first workshop measuring retention of knowledge and skills, this was ultimately not feasible in light of time and resource constraints.  Subjectively, the students expressed that they very much appreciated the opportunity to reinforce and practice their skills.  I could see that many were more prepared to revive their mock newborn patients, and to do so within the first minute of life.  The second session also gave me the opportunity to fine-tuning practices that I had observed in the delivery room during my month, for example: not delaying bag mask ventilation to attach oxygen to the self-inflating ambu bag and acting upon an emergency plan (i.e. calling Carlos) at the first sign of trouble, whether fetal distress or difficulty with ventilation. 

Carlos (pediatrician in-charge) and I.

Lastly, I worked with one of the hospital administrators and Carlos to create a self-evaluation tool for the pediatrics unit that could be used to highlight and select priority issues for quality improvement.  Drawing from hospital standards from the WHO, the Mexican General Health Council, and other resources, the tool asks doctors and nurses to respond to questions relating to seven themes using Likert scales: professional communication, medications and errors, rights of the hospitalized child, involvement and education of families, evaluation and treatment of pain, hygiene and prevention of infection, personnel and equipment, and trainees and continuing medical education.

I truly hope that I will have an opportunity to return to Chiapas and to Hospital San Carlos.  My upcoming fellowship program in pediatric emergency medicine is affiliated with two hospitals, UCSF and Highland, who send attendings and residents to San Carlos.  Now that I’ve had a chance to reflect on my trip, it’s time to get busy thinking of next steps.  Next steps in strengthening the Hospital’s referral capabilities, perhaps via telemedicine … next steps in ongoing capacity-building in skills such as neonatal resuscitation and pediatric ultrasound.  I’m so grateful to all my new, amazing colleagues in Chiapas, the sisters of Hospital San Carlos, Dr. Jennifer Kasper, Dr. Juan Manuel Canales, and Doctors for Global Health, who together made this experience as enriching as it was.  Many thanks as well to MGHfC Pediatric Residency Program and the Partners Center of Expertise in Global and Humanitarian Health without which this incredible experience would not have been possible.

Ashkon Shaahinfar, MD, MPH
MassGeneral Hospital for Children
Pediatrics, PGY3