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Friday, January 10, 2014

Ultrasound in South Sudan: what might it be good for?

Last month I spent 2 weeks in a small hospital in South Sudan and probably did about 100 bedside ultrasounds. The whole experience was very moving, and encompassed so much more than doing ultrasound, even though I had intended the trip to be primarily for teaching ultrasound applications. It turned out that I also had to learn as much tropical medicine as my aging brain could hold and clean up spider webs and feed people and put goop on rashes and sew up gashes and learn to say hello in Nuer and a number of other things which will occupy an important place in my heart for years.

But as an ultrasound nerd, there were many exciting nerdy moments. These were the moments that most ultrasound nerds experience when we realize, again, that this technology is totally cool and that we wish everyone could do it.

I have spent the last 2 years practicing hospital medicine and a little bit of primary care and doing thousands of bedside ultrasounds. I have taken classes and tests and spent free moments studying ultrasound anatomy books. I have taught students and shared pictures with specialists and attended meetings. I have ultrasounded friends and family members, my dog, taken a fellowship, bought 2 machines, given one away. All because ultrasound is cool. It is indescribably awesome to look inside a person's body without hurting them.

In the United States I use bedside ultrasound to answer pretty specific questions that are relevant to my practice. Is the heart function normal? Is there fluid in the belly or lungs which shouldn't be there? Do the kidneys and bladder empty properly? What do the great vessels say about hydration status?

In Africa I had less standard testing to help guide diagnosis, so the ultrasound got to tell me more information. Here are few ways it helped me:

1. Strong guy, walked in limping, having stepped on a thorn 5 days before. He was sure there was something in his heel. I hate getting foreign bodies out of heels. It really hurts and the flesh is so firm that it is nearly impossible to explore a heel. I had only the phased array transducer for visualizing large deep structures, but by using a rubber glove filled with water as a stand-off pad I was able to visualize an echogenic long thin thing about 2 cm down, numbed it up generously, sliced it open and pulled out a big thorn. Wow. Just like in the movies!

2. Two women came in very short of breath after long journeys. Tuberculosis is endemic in South Sudan. Both had pericardial tamponade with moderate effusions and calcified pericardia, probably indicative of chronic tuberculous effusion. TB is treatable, but definitively treating pericardial tamponade was not practical. Diagnosing the condition was interesting from an imaging point of view, but the two ladies died anyway.

3. A couple of patients had kidney failure. By history it seemed likely that it was not new, but ultrasound was helpful in ruling out obstruction and the kidneys of both were echogenic suggesting that the condition was not likely to improve much.

4. One patient appeared quite short of breath, but it was unclear if she had asthma or pneumonia or something else. There is no x-ray machine. The ultrasound showed bilateral pleural effusions which strongly supported a diagnosis of tuberculosis. This was treated effectively with anti-tuberculosis medications and steroids. Her pleural effusions nearly disappeared within a few days of treatment.

5. An old man had been discharged for presumed congestive heart failure. He was clearly going to die, and his daughter had taken him to a hut in the village before taking him home. His ultrasound showed a huge tumor in his chest cavity displacing his heart, which otherwise functioned just fine. His heart medications could be stopped.

6. A young woman had come in to the hospital with a premature delivery and post-partum hemorrhage. She was anesthetized and the retained placenta was manually extracted, but it was not clear that it had been completely removed. Ultrasound showed an empty uterus, allowing her to go home when she had stabilized.

7. Other women with vaginal bleeding could either go home if they were stable, with a completed miscarriage, or could be counseled to rest if a pregnancy could be visualized.

8. There were leg infections which were slow to heal, some with pus collections that had been drained. Ultrasound could tell us if they needed repeated drainage.

9. A woman with a suspected ovarian cancer had a painfully huge belly from ascites. She responded pretty well to therapeutic paracentesis, but the ultrasound was very helpful in allowing us to dodge the large peritoneal tumor masses that might have caused bleeding.

10. Evening clinic often brought babies who were under the weather. Doctors in South Sudan see enough untreated congenital heart disease that they could be reasonably certain of a diagnosis of ventricular septal defect. Still, seeing the hole in the heart on ultrasound and the degree of heart enlargement was very useful. Some babies can make it to Khartoum, the capital of Sudan, and may be eligible for free heart surgery.

...and also so many reassuringly normal or near normal ultrasounds.

How and who to teach in this setting is a good question. Caregivers have varying backgrounds and must actively develop new competences when patients are sick and demand is high. It is interesting that the ability to visualize a person's internal organs with ultrasound and correlate those pictures with previously learned anatomy does not necessarily spring from an extensive medical education. Some people are just good at it. I encouraged the people I taught to ask specific questions rather than looking for weird things like tumors. Finding a normal fetal heartrate, determining fetal presentation and estimating fetal age are very useful and not hard to learn. These will be possible to learn and practice with a little bit of supervision. Finding fluid in the belly is easy and potentially very useful. Detecting fluid in the lungs will take a little more work, but should be easy eventually. Looking for a full or empty bladder should not be too hard to master. Most hearts will be normal, so detecting that there is something wrong should come with a little practice. Diagnosing exactly what is wrong is quite a bit trickier. Protocol driven diagnostics and treatments have been very effective in resource poor settings, so a more complete training course should probably include a protocol of when to do ultrasound and what questions are reasonable to ask.


2 comments:

DocAmazing said...

Thank you for that article. I'm a pediatrician, and I'd love to do fewer X-rays. After reading what you've written, I'm going to talk to the radiologists at my hospital about ultrasound diagnosis of pneumonia and fracture in kids less than four years of age.

Janice Boughton said...

Radiologists have been really slow to embrace ultrasound for lung imaging. It seems like it's the emergency docs who are more motivated for point of care solutions who are pushing it. There are also some Italian docs who are doing it. For me, I find that identifying and characterizing pleural effusions is the most powerful technique, and ultrasound is so much better than chest x-ray for that. Ultrasound findings of wet lungs are also useful and not hard to identify and more sensitive that chest x-ray for interstitial edema. For things that are wet, ultrasound may be more sensitive than CT. I met an excellent pulmonologist in Puerto Rico who used ultrasound routinely for diagnosis and relied on it much more than standard x-rays, but it takes lots practice to identify lung parenchymal abnormalities and they don't teach that to sonographers or radiologist. Good luck--I hope they go for it!