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Monday, March 12, 2012

Yale University Ultrasound Course in Puerto Rico and learning from resource limited settings.

I just got back from Puerto Rico, where I attended Yale University School of Medicine's yearly emergency medicine and critical care ultrasound course. First, Puerto Rico is a tropical island in the Caribbean which has been relatively blessed by the universe, at least as compared to Haiti which is within hailing distance. It uses American currency, has American style roads, mostly deals in English but has rain forests and warm beaches and loud tree frogs and quiet bats that make being outside at night amazing and other worldly. It is not very expensive to fly there, even from the west coast. It is not as cheap as other developing countries, but not as expensive as traveling in the US. It was wonderful to go there in March. I don't usually do this sort of thing, the resort vacation that becomes a tax deduction because of medical education, but this one had fantastic faculty and was everything I could have hoped for.

I have been excited about bedside ultrasound since I took a course at Harvard in November. I have been using ultrasound at the bedside ever since then, and getting better at it all the time. It takes a huge amount of time, though, to get competent at finding the right angle and location to look at the various innards and figuring out what it is that is actually in that image. I am having to really relearn my anatomy. Every time I am taught, hands on, by someone who is really good, I progress by leaps and bounds.

The faculty for this Yale course included Chris Moore MD and Katja Goldflam MD, excellent teachers, both of whom have emergency medicine backgrounds. They really know their stuff, and have designed a curriculum that they use with medical students and residents at Yale. The course consisted of basic concepts, lots of cases with video clips of ultrasounds and many hours of hands-on experience with healthy volunteers. The food was also great.

There are accepted uses for ultrasound, like evaluating kidneys, babies, hearts and gallbladders, bedside uses that not everyone knows about, including guidance for procedures and evaluation for collapsed lungs or fluid where it shouldn't be, and there are ultrasound techniques that are frankly entirely dismissed by most doctors, which include evaluation of the bowel, the lungs for pneumonia or congestive heart failure. At the course I was most impressed by one of the participants who is a pulmonary and critical care physician, trained and working in Puerto Rico. His knowledge of ultrasound was impressive, and he said that he routinely uses ultrasound in his office to diagnose pneumonias, because it is more accurate than chest x-ray.  This sounded intriguing, but I couldn't quite believe it. So I checked it out, and sure enough, a group in Italy has been publishing reports of how much more accurate ultrasound is than chest x-ray, using CT scanning of the chest as the gold standard.
http://www.ncbi.nlm.nih.gov/pubmed/19555605 since at least 2009.

I find it interesting that in resource limited settings, like Puerto Rico and Italy, technology that is better is used more often than it is in the US. Cost incentives clearly have something to do with it, since people make very little if any money by performing bedside ultrasounds, and it takes more training to evaluate the lung with ultrasound than to order a chest x-ray. The ultrasound uses no resources and requires no third party to read it.

I'm thinking that there are probably many other tricks that physicians in resource limited settings use that are more effective, not even just more cost effective, than what we do in the US.

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