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Friday, February 21, 2014

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

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, and 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. Tuberculosis 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.
11. 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 heart rate, 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.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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