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Friday, January 30, 2015

Bedside ultrasound in the developing world: What is it good for?

In the last year and a half I've been able to go to Africa 4 times and Haiti once, for which I give thanks that the world still produces abundant fossil fuels. That much airplane travel does make me feel a bit guilty, even though I'm not actually vacationing.

Going to faraway places to practice medicine has always been something I hankered after, and it turns out that knowing how to do and teach ultrasound is a good way to get invited to exotic places. I think if I could do cleft palate surgery or eye surgery or had a traveling dentistry practice I could also be useful in foreign lands, but as an internist it is more difficult to find something that I can do well in a hit-and-run fashion which actually benefits people. Bedside ultrasound, particularly teaching it, fits the bill.

Forgive me for repeating myself if you've already heard the story, but when I quit my regular primary care practice, I learned to do bedside ultrasound. I fell quickly in love with the ability to see inside people, sharing with patients their living anatomy, quickly making appropriate diagnoses and designing appropriate management, following patients' response to therapy. I learned how to ultrasound the heart, lungs, liver, gallbladder, kidneys, bladder, spleen, intestines, great vessels, and also how to teach other people. It's been exciting and time consuming and tons of fun, and has become an integral part of my practice as an internist and hospitalist. I've written many blogs about how ultrasound has changed my practice, but I still get the question, “What's it good for?”

What it's good for varies according to the setting. A bedside ultrasound is usually done with a machine that is small enough to carry in one hand. Mine, a General Electric Vscan, is about a pound and has a screen that is just a few inches across. It gives surprisingly good pictures, but they are nowhere as good as the big ultrasound machine in the radiology suite. If that big machine was pocket-sized, I'd be like the doctor on Star Trek. Because the bedside machines are smaller and less expensive than the full size ones, their resolution is a little bit worse, so they are best for asking relatively simple questions. Also bedside ultrasound is performed by doctors who also do things other than imaging and haven't spent the extensive amount of time radiologists have in learning subtleties of reading radiological images.

At my hospital in the U.S. I can answer questions with my small ultrasound machine like, “Is there fluid in the peritoneum?” or “Are there gallstones?” or “Is the heart squeezing OK?” or “Are the kidneys/ureters blocked?” I can feel confident about whether the bladder is over-full or whether there is fluid or infection in the bases of the lungs. I can see pulmonary edema and amounts of pleural fluid that are too small to be seen on X-ray. I can follow the course of intestinal distress such as gastroenteritis or obstruction. Sometimes I can't see enough to say anything, most often if the patient is hugely fat or is plastered with bandages or stickers that I can't remove. If I need to really know what is going on inside a patient who I cannot image with a bedside ultrasound, I can order a radiological study and usually get my answer in a reasonable time period. When I can look myself, though, my treatment decisions are more fluid and timely.

In the developing world there are fewer X-rays and CT scans available, less official ultrasounds, and having the ability to do bedside ultrasound is pretty magical. There are many ultrasound machines in these out of the way places, and what is mostly needed is training. There could be more machines, of course, and when it becomes more clear how useful the technology can be, more resources may be focused in that direction. I have ultrasounded in Tanzania and South Sudan and the island of La Gonave, off the coast of Haiti, and the procedure, quick, painless and free, was profoundly influential. Last month while I was in South Sudan there was a war on nearby, and there were freshly and not so freshly wounded soldiers, which was a new thing for me. Here are a few cases of exactly what ultrasound has been good for in the developing world:
1. Young man with a gunshot wound to the leg. Is it broken? Is there a pus collection? Ultrasound is really good for ruling out long bone fractures and finding subcutaneous fluid collections. The wound was only in the muscle and a little cleaning and bandaging did the trick. No need to transfer this one to a higher level of care.
2. Different young man was injured in the face with shrapnel. He is unable to see out of one eye. Is the retina damaged (a bad sign)? Ultrasound is quick and efficient as a tool for looking at the eye, especially if the patient is unable to open it for an exam. This guy did have a thickened and abnormal retina with evidence of blood in the posterior chamber and a metallic foreign body. He is not likely to get his sight back in that eye.
3. Little boy shot in the chest and short of breath. Is it a punctured lung? A burst blood vessel bleeding into the chest? Is the heart damaged? For this boy it was none of these things, but a contusion of the lung, which looks a bit like pneumonia on ultrasound. A chest tube would have further compromised that lung and the boy avoided this procedure. Where is the bullet? It would have been great to have an X-ray to find that out!
4. A young woman with vaginal bleeding after 3 months of thinking she was pregnant. Is she having a threatened miscarriage or is this just an irregular period? Ultrasound is wonderful for seeing a uterus and whether there is a baby hiding inside. We saw many of these cases. Sometimes there was a baby, sometimes not. The treatment, bed rest vs. normal activity, was very different and knowing which was indicated could profoundly impact the whole family.
5. A little baby with an enlarging lumpy area on the lip. I could just imagine all of the creepy things it could be. The ultrasound showed it to be made up of blood vessels, so it is a cavernous hemangioma, which is a common benign tumor in infancy and usually goes away or shrinks by itself, and sometimes requires medications to help it go away.
6. A young man has been getting weaker, with swollen legs and a barrel chest. Is it heart disease? Perhaps something he was born with? These might be treatable with medications. Unfortunately it was not. There was a huge tumor obstructing blood flow to the heart and lungs. Good to know, though heart wrenching.
7. An old man, failing to thrive. He has back pain. Ultrasound shows he has a large bladder tumor which is blocking his kidney. Caught this late, and in a war zone, this is not treatable. Knowing helps his family to make plans.
8. An uncharacteristically pudgy woman with recurrent abdominal pain. Is it an ulcer? Actually no, her gallbladder is full of stones and is tender to push on. Surgery will help, and this lady lived in a place where that was safe and available.
9. A young woman with pelvic pain. Is it a tubal infection? A bladder infection? It is not hard to visualize the abdomen and pelvis with ultrasound, and this person had a ruptured ectopic pregnancy with blood loss into the abdomen. She will die without surgery and she will likely do fine with it. She was rushed, appropriately, to surgery.
10. A woman with a full term pregnancy: she hasn't been feeling the baby move. Is it in trouble? Ultrasound is absolutely wonderful for looking at babies, since they float around in a big balloon of water. This woman's baby looked healthy. Good news.
11. A woman acutely short of breath, with some chest pain: is it asthma (common) or her heart? Strangely enough her heart wasn't squeezing very well and her lungs looked wet. She responded well to medications for pulmonary edema and was fine the next day. I have no idea what that was about, and can't find out further because I'm home and she is probably lost to follow-up.
12. Pyomyositis: people get collections of pus in their legs and sometimes arms for no obvious reason. Then they get very sick and if the pus is not drained, they die. When a leg is swollen up it's pretty hard to know where to cut to release the pus unless something like an ultrasound tells you where it is. We doctors love draining pus. The young man in question, a retired child soldier, had relief of his condition and will get well.
13. A soldier, clearly sick after being shot in the belly: Has be bullet injured a blood vessel or vascular organ? Is there a significant amount of free air to suggest a major intestinal perforation? The FAST scan (focused assessment with sonography in trauma) looks for fluid, usually blood, in the belly and can determine whether a patient needs emergency surgery, if available, to avoid bleeding to death. Lots of free air looks like air anywhere, with air artifact and multiple parallel horizontal lines. This young man had peritonitis, with thickened bowel walls, fluid filled bowel loops and small amounts of fluid between the intestinal loops. He was transferred to a higher level of care after receiving antibiotics and fluids.

Also … babies with loud heart murmurs, young men with testicular swelling, the worried well … ultrasound in the developing world is great!

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 Iowa City, IA, 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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