American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, February 29, 2016

Old Fangak, South Sudan, bedside ultrasound and other stuff

I just got back from a couple of weeks in Old Fangak, a community of people living by the Zaraf River in South Sudan. It's normally a small community, with an open market and people who live by raising cows, trading on the river, fishing and gardening. Now there are tens of thousands of people there, still displaced from their homes by the civil war which has gone on intermittently for decades. There are even more people now than there were last year.

There is a hospital in Old Fangak, which is run by Jill Seaman, one of the founders of Sudan Medical relief and a fierce advocate for treatment of various horrible and neglected tropical diseases, along with some very skilled and committed local clinical officers and nurses and a contingent of doctors, nurses and support staff from Medecins Sans Frontieres (Doctors Without Borders, also known as MSF) who have been helping out for a little over a year. The hospital attempts to do a lot with a little, and treats all who present there with whatever is available to combat their myriad ills. There are special programs for children with severe acute malnutrition, for patients with tuberculosis, kidney disease, Kala Azar, including food distribution for a subset of people with chronic illnesses.

I've been to Old Fangak 3 times now, always in the winter (warms my toes for a few weeks) during their dry/cool season. Cool means that it doesn't get much above 100 degrees during the day and cools down to sometimes below 70 at night. My stated purpose in going is to teach Jill and anyone else who wants to learn how to do bedside ultrasound. I love teaching people to do ultrasound and it means that a 2-week trip can actually have some long lasting benefits. I also get to be a general, all-purpose doctor who can give shots to babies, sew up lacerations, trim down leprous calluses, ponder the etiology of obscure illnesses and cook dinner. I get to see how the staff at the hospital manages to do the loaves and fishes trick with far too many diversely sick people and far too few resources.

They have a work horse of a Sonosite MicroMaxx ultrasound machine which is good for anything from babies to hearts to fractures and abscesses. I got to teach a midwife who has seen other people use ultrasound but hasn't been able to do it herself, an ER doctor who had only previously learned to do ultrasound to identify blood in the abdomen in patients with blunt trauma, and a nurse who will likely make international medicine her career and was an awesomely quick study. Jill was already quite good with obstetrical ultrasound but became more confident with hearts and abdomens. Everyone learned how to make gel with glucomannan powder for when the carefully hoarded real ultrasound gel goes mysteriously missing. I brought my Vscan (little pocket ultrasound) for ultrasounding on the fly, and that was really useful as well.

An ultrasound machine paired with a person who can use it makes a big difference to care in the U.S., but is life-alteringly amazing in a rural hospital in Africa. What, you might ask, was it good for?
1. An old woman limped in with a hard lump sticking out of the top of her foot. It had been swollen in the past, but now just hurt. It started when she kicked a tree. I can check it out by putting her foot in a tub of water and using the ultrasound transducer to see whether the little lump is a foreign body or a bone. Unfortunately it was a bone, sticking out of the top of her foot. Ouch. Not a lot to be done for that in this situation.
2. Babies. So many babies! One night there were 2 sets of twins delivered in 1 hour. The ultrasound could confirm the positions of the little tykes and predict the ease of delivery. The first pair were both head down and came out without a hitch. The second pair were smaller, worrisome for prematurity, and after the first 1 emerged (squalling nicely) the second 1 was lying in a transverse position. With a little manipulation from the outside, she was able to flip so that the head was down and was delivered without incident. There were slow or obstructed labors and being able to know that the baby was alive and well meant that the mother could be motivated to push hard even though she was really tired.
3. Abdominal pain in a person with known hepatitis B: Hepatitis B is unfortunately still quite common, and vaccination is not standard. One relatively young woman had been treated for hepatitis B but was having pain in her abdomen. The ultrasound showed a small nodular liver and ascites, but a small enough amount that removing it might be dangerous and certainly wouldn't make her feel better. Treatment with anti-viral medications was indicated, paracentesis (removing fluid from her belly) was not.
4. A pregnant woman was very anemic and also nauseated and unwilling to eat. On ultrasound her baby is still doing OK, but her amniotic fluid level is a bit low. When the transducer peeked around the uterus there were multiple loops of large bowel that are filled with fluid and thickened. In this situation the most common cause of such a finding is giardia, an endemic intestinal parasite. She got intravenous hydration, treatment for her giardia and her nausea magically resolved. She had lain in the hospital for over a week being miserable, but the ultrasound was able to point us towards the right diagnosis.
5. Heart disease is common there as it is here, but in Old Fangak it is primarily due to birth defects or rheumatic fever. A man presented to the hospital with swelling of his legs and shortness of breath. He was exhausted. He hadn't been able to lie down to sleep for months. He was treated with diuretic medication and beta blockers to slow the heart and improved quite a bit. The ultrasound showed advanced rheumatic heart disease, with a stenotic mitral valve and a leaky aortic valve. It was nice to know, and perhaps an e-mail to specialists in Khartoum, the nearest city with really high quality medical care could secure him the heart surgery he needs. Probably not, but it's worth a try. There were children with signs of heart failure due to ventricular septal defects and a young woman as well, probably with an atrial septal defect. They could live relatively normal lives with heart surgery, but the Italian group that used to do this for free in Khartoum is no longer providing that service. They will get medicines which will work a little bit and they will probably die young. Stuff like that is hard to watch.
6. Pus. People come in with swollen hands, fingers, thumbs, feet. There was a guy with a swollen thumb. After the obvious pus was drained there was still pain and swelling. We could see with the ultrasound that there was very little pus left to drain, but that the bone in the last joint of the thumb had broken due to the infection, suggesting a need for amputation of that bone. Another guy had a swollen finger, with pus on both sides of the tendon. This guided the drainage procedure. He didn't have obviously infected bone and might well recover the full use of his index finger.
7. People also became desperately ill sometimes, short of breath, low blood pressure, that sort of thing. A woman with a history of heart problems in the past came in unable to catch her breath, with a fever. Ultrasound showed that her heart was doing just fine and that her inferior vena cava was very small supporting a diagnosis of sepsis and pneumonia and leading to successful treatment with fluids and antibiotics. Another woman had known kidney failure and came in with a cough. The ultrasound also showed normal heart function, an abnormal left lung and dehydration in her. She was treated with intravenous antibiotics and fluids. The next day the inferior vena cava was full, meaning that she did not need more fluids, and her bladder was full as well, showing that she did have some residual kidney function. Her overall prognosis is terrible, but she was able to survive another few days at least.

So bedside ultrasound clearly rocks. Living in South Sudan and being sick does not.

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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Blogger JLalonde said...

Fascinating and sad.
Thanks for the reminder of what they face in poverty stricken nations. Despite our health care issues, we have a lot to be thankful for here in the US.

March 4, 2016 at 5:05 PM  

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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).

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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.

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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.

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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.

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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.

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