The improvement and miniaturization of ultrasound devices is a result of the need to make ultrasound devices quickly accessible regardless of location. The right diagnosis at the right time in the right place can take you a step ahead in this race for point-of-care diagnosis.
Developed countries have experienced very significant direct and indirect impacts on the quality of care for patients in acute care and those who are hospitalized. However, if in these countries, ultrasound has made it possible to bypass certain additional examinations (standard radiography, CT, MRI, etc) for certain precise indications despite the latter being nevertheless available, it can be deduced logically that under certain conditions, point-of-care ultrasound (POCUS) would have an even greater impact in settings where other modalities are simply not available.
Indeed, developing countries and areas with limited resources often have in common a lack of diagnostic imaging means: old, non-mobile X-ray machines with little or no function at all and you’ll rarely find CT or MRI, and when you do, it is inefficient except in concentrated, large cities.
Add to this an extremely limited electricity supply, which significantly reduces the effectiveness of the existing means even further. It directly results in the impossibility of full-time operation due to power cuts, and indirectly through breakdowns and the gradual deterioration of the equipment related to variations in electrical voltage.
These various problems make Africa extremely fertile ground for the use of clinical ultrasound (POCUS) with exactly the same benefits as those obtained in other better-developed regions, but better still the absence of other means of diagnosis, which could lead clinical ultrasound to become the “gold standard” for clinical diagnosis in African.
The problem, however, is the availability of the devices, especially the type of device. Indeed, the devices currently present in Africa are either static or relatively portable (more than 10kg), which poses a real problem of mobility for an imaging modality that could otherwise be performed at the patient’s bedside.
Ultraportable devices with their small size, their resistance, their autonomy, and their low energy requirement could be a valuable diagnostic aid in Africa. However, there remains the problem of their availability (most manufacturers limit their network to developed countries) and their cost (due to the low purchasing power of practitioners in developing countries), the very idea of obtaining one at its actual cost is completely illusory.
What if the manufacturers of ultraportables developed strategies to support doctors who want to equip themselves and the educated societies with POCUS, set up conventional classroom-based training courses and E-learning free or at a reduced price for all doctors wishing to learn?
Yannick Ndefo, MD, is a general practitioner in Cameroon and a POCUS ambassador for POCUS Certification Academy.
Interested in learning more about ultrasound in global health? Check out these posts from the Scan:
The infant, carried by her father, had been vomiting for several days. The patient’s history was consistent with pyloric stenosis, but there were still other differential diagnoses to consider. The surgeon caring for the patient was trained in Morocco and France. He was an excellent physician who returned to his community in the small coastal country of The Gambia in West Africa. The physician needed diagnostic ultrasound to confirm or refute the presumed diagnosis. He was plagued by indecision at the prospect of performing unnecessary surgery on the infant. The patient had traveled at great cost and distance to arrive at the only tertiary care center in the country. Her family needed help and if they could not find it here, they were out of options.
At the invitation of the surgeon, I was taking the entire attending physician group from every specialty available through a point-of-care ultrasound (POCUS) course. The course was tailor-made for surgeons, despite having representatives present from internal medicine and pediatrics. It was reasoned that the largest immediate gains would be from trauma care, ultrasound-guided procedures, and confirmation of surgical diagnoses and complications. The amount of blunt trauma and blind procedures including liver biopsies was staggering.
Each day focused on problem-based and group learning, with gamification and competition built it. The goal was to keep the learners engaged and follow up with deliberate practice every afternoon. The surgeon would bring patients from the hospital who required diagnostics, which were unavailable until now. Patients made the trek up 2 flights of stairs, where we were teaching in the only air-conditioned space. Conditions that would be identified early in high-resource regions are often elusive without the necessary diagnostics. With POCUS, we identified patients with heart failure, pneumonia, bowel obstructions, appendicitis, and complications of pregnancy. We also identified conditions that are less readily seen in high-resource health systems such as rheumatic heart disease and hepatic abscesses.
Each day focused on problem-based and group learning, with gamification and competition built it. The goal was to keep the learners engaged and follow up with deliberate practice every afternoon. The surgeon would bring patients from the hospital who required diagnostics, which were unavailable until now. Patients made the trek up 2 flights of stairs, where we were teaching in the only air-conditioned space. Conditions that would be identified early in high-resource regions are often elusive without the necessary diagnostics. With POCUS, we identified patients with heart failure, pneumonia, bowel obstructions, appendicitis, and complications of pregnancy. We also identified conditions that are less readily seen in high-resource health systems such as rheumatic heart disease and hepatic abscesses.
The surgeon confirmed the diagnosis of pyloric stenosis during our POCUS course. He took his patient to the operating theater with confidence and she did well postoperatively. Ultrasound continues to make a lasting impact in The Gambia. Together, we are building a sustainable program that will incorporate POCUS into all graduate medical education. POCUS impacts care wherever it is used by trained professionals, but in my experience, it is the single most important diagnostic tool in low-resource health systems.
Michael Schick, DO, MA, MIH, FACEP, is an Assistant Professor of Emergency Medicine and Director of International Ultrasound at UC Davis Medical Center.
Interested in reading more about POCUS medical education? Check out these posts from the Scan:
The health systems of most underdeveloped countries have one thing in common: the total absence of health insurance. The entire cost of illness is borne by the patient and their family. If we add to this problem low and uncertain incomes, the result is patients who often do not have enough money to pay for their health care. In the best cases, we have patients who will be content to pay only for the minimum and essential care since they cannot afford more. This very often leads to insufficient care.
Patient spending in a hospital is generally based on 2 components:
Expenses related to diagnosis: Complementary biological and imaging tests
Expenses related to care: Medications and care
The impact of poverty and the indigence of the patients will weigh as much on one component as on the other. The patients will only agree to undergo an examination if they are convinced that it will bring vital information. Similarly, among the prescribed drugs and treatments, they will spend only on what seems to them vital in the immediate future or essential to save a life in the short term. The direct consequence is an increase in morbidity and mortality, and an increase in costs per relapse and re-hospitalization, frustration, etc.
There is, therefore, a major problem in the practice of medicine in poor areas:
How do we convince the patient it is worth their money?
How do we make them realize the degree of urgency and dangerousness of the pathology?
It is recognized worldwide that an image is worth a thousand words and images are what ultrasound offers us.
The whole world is learning a little more every day to appreciate the diagnostic and therapeutic value of ultrasound, but one of the most impactful elements that can be achieved with ultrasound is communication, the transmission of information.
The disease is no longer just abstract. We can show it to the patient, we can see his eyes fill with gratitude when he finally manages to see what is hurting him, what has caused him so much worry. We go from the abstract to the concrete.
If this is already a plus in developed societies where the patient wants to satisfy his curiosity, get information, and understand, in underdeveloped countries a new aspect emerges. The patient can see what he is going to spend his money on, why he will pay for transport from a village to the city to see a specialist or carry out an expensive examination, why he will accept that a needle is inserted into his body, why his stomach will be opened.
Ultrasound can literally boost compliance with treatment and it seems to be magic that the benefits of ultrasound are the same regardless of the environment.
To illustrate my remarks, I present to you a 50-year-old patient, with high blood sugar levels for 3 years, which was not monitored because she believed that she could control this with plants and bark. On examination, we found a painful epigastric mass in the left hypochondrium, which was mobile with respiration. The ultrasound found a voluminous left renal abscess. Thanks to the ultrasound image, and the comparison of the two kidneys, I was able to convince the patient to travel to the city, to pay for an abdominal CT-Scan (the price of which represents her wage over 4 months) and to undergo ultrasound-guided percutaneous drainage (Figure 1).
Figure 1. Left, Ultrasound image of the left renal abscess and a normal right kidney.
Figure 1. Right, CT scan of the left renal abscess and the normal right kidney.
The benefits of communication with ultrasound are even greater when it comes to point-of-care ultrasound (POCUS). You are the examining doctor, you tell the patient what you suspect, you scan their body to answer the questions you have asked, and when you have the answer, it is a moment of bonding and complicity between you and the patient that only those who use POCUS can understand. BEAUTIFUL!!!
Any doctor practicing in rural areas, remote areas, or poor areas should learn to do POCUS. With online learning, everything is accessible now. Free or inexpensive online courses and scholarships for developing world doctors should be strongly encouraged. Ultrasound societies must look into offering such content. Universities should as well because the future of health will develop with POCUS.
If we want to help poor countries progress, knowledge sharing must be at the center of the priorities. We need to take into account inequalities that result in health personnel who most need POCUS are also those who are not able to afford training whether online or face-to-face. It is necessary to ensure that there are elite developing-world doctors who have mastered POCUS, and who will be able to teach it to others and thus participate in the popularization of ultrasound.
Let’s democratize ultrasound, and save lives.
Yannick Ndefo, MD, is a general practitioner in Cameroon and a POCUS ambassador for POCUS Certification Academy.
Low- and middle-income countries have always faced major health difficulties related to lack of human resources, facilities, and access to drinking water and electricity. Added to these factors are the lack of a suitable road, geographical remoteness, and poverty. Hence, the management of patients is compromised both diagnostically and therapeutically.
Point-of-care ultrasound (POCUS) offers wide possibilities to health professionals who work in areas with limited resources by means of the portable machine with a good battery. Therefore it is possible for the clinician to go to low- and middle-income countries to dispense quality care services on the spot while giving access to diagnostics and guiding the management and emergency invasive procedures.
As a primary care physician, I was trained on clinical ultrasound through the Canadian platform in the emergency unit. I use it in my routine practice as part of my physical exam with my patients, which greatly increases my precision. No words are strong enough to describe how we feel when we examine a young woman who consults for severe pelvic pains associated with metrorrhagia and we suspect an ectopic pregnancy and the B-HCG urine test comes out positive, so you grab your US probe and you find an empty uterus, a hemoperitoneum. The fact that you saw the patient’s interior and were to be able to show her what exactly is wrong…. It’s a strength beyond what the words can explain, the precise diagnosis is reliable and prompt.
Once a month, I travel to Yabassi, a small village surrounded by a forest in the littoral region of Cameroon, which is difficult to access and rarely supplied with electricity, to do ultrasound for pregnant women discouraged by the bad state of the road and the distance to reach the nearest town. I help them meet their babies for the first time and I enable adequate follow up for the pregnancy and prevent certain complications that might occur during the delivery.
With a minimum of 1 doctor for 30,000 people, it is imperative for the clinician to go to the patients and not the reverse. And POCUS can help in these situations because of its ability to save the images to be shown to other experts for their expertise if needed. Ultrasound offers immense possibilities in upper-income countries, and I think it’s even more important in low- and middle-income countries to have access to that highly efficient and accessible method, to greatly improve the management of patients while offering quality healthcare at a low cost.
Yannick Ndefo, MD, is a general practitioner at St Thomas hospital in Douala, Cameroon.
Interested in learning more about ultrasound in low-resource settings? Check out the following posts from the Scan:
As I write this, the novel coronavirus COVID-19 is spreading across the globe, inciting fear and anxiety. Aside from frequent hand-washing and other routine precautions, many leaders, officials, and bloggers are advocating for limiting person-to-person contact. This has resulted in cancelation of many professional society meetings, sporting events, and social gatherings, and has stimulated new conversations regarding working from home and virtual meetings. Although these suggestions have many clear benefits (such as the decreased burden of commuting; limiting the spread of infection), there are additional reports describing the impact loss of face-to-face interactions may have on job satisfaction, workflow efficiency, and quality.
The current practice of medicine, more than ever, relies on a team approach. No one individual has the time, knowledge, or experience to tackle all aspects of an individual’s care. No one is an island. Unlike many television shows that highlight a single physician performing everything from brain surgery to infectious disease testing, the reality is that we each rely on countless other members of the healthcare team. That practice of medical imaging, ultrasound, in particular, is no different. Whether we work in a radiology, cardiology or vascular, or obstetrical/gynecology practice, the team, and more importantly the relationship between team members, is paramount to an effective and impactful practice.
As a radiologist in a busy academic center, I rely on and value my personal relationship with my team of 50+ sonographers. These relationships have been facilitated by day-to-day, face-to-face interactions, allowing me to get to know the person behind the ultrasound images. These interactions foster an environment of trust. For my most experienced sonographers, my implicit trust ultimately leads to fast, efficient and precise exam interpretations, while for sonographers I rarely work with, my index of suspicion regarding a finding is naturally heightened, impacting my confidence in my diagnosis and thus affecting my interpretation, and ultimately how my report drives patient care.
The trust goes both ways: a strong relationship also fosters honest communication whereby sonographers can come to me with questions or concerns regarding exam appropriateness, adjustments to imaging protocols, and the relevance of a specific imaging finding. The direct interaction provides an opportunity for sonographers, new and experienced, to be provided immediate direct feedback regarding their study—they can learn from me, and often I from them, making us all that much better at the end of the workday.
In addition to trust, open communication allows for users of ultrasound to take advantage of one of the key differentiating features of ultrasound compared to other modalities: the dynamic, real-time nature of image acquisition. Protocol variations can be discussed on-the-fly. Preliminary findings can be shared with the interpreter, and additional images can be obtained immediately, without having to rely on call-backs, inaccurate reports, and reliance of follow up imaging (often by other modalities). This ultimately enhances patient care and decreases healthcare costs. In our practice, we have the ability to add contrast-enhanced ultrasound for an incidental finding, allowing us to make definitive diagnoses immediately, without having to recommend a CT or MRI—this would not be possible if it were not for a personalized checkout process.
We continue to hear about changes in ultrasound workflow across the country: sonographers and physicians, small groups and large, academic and private practices have all considered or have already implemented changes that minimize the communication between sonographer and study interpreter. This places more responsibility on the sonographer to function independently, and minimizes or even eliminates the opportunities for quality control and education. Sonographer notes and worksheets, and electronic QA systems, are poor substitutes for the often more nuanced human interaction. In my experience, these personal encounters enhance job satisfaction, and the lack of it risks stagnating learning and personal drive. There have been many sonographers that have left local practices to join our medical center specifically to take advantage of the sonographer-radiologist interaction we continue to nurture.
Some elements driving these transformations are difficult to change: growing numbers of patients; increasing reliance on medical imaging; medical group consolidation; etc. Many changes to sonographer workflow have been fueled by a focus on efficiency (decreasing scan time, improving modality turn-around times, etc.). Unfortunately, these changes have been made with little regard to how limiting team member communication impacts examination quality, job satisfaction, and patient outcomes; for those of you in a position to address workflow changes, consider these factors. For sonographers yearning for this relationship, do not be afraid to reach out to your colleagues and supervising physicians—ask questions, be curious, and engage with them. Nearly everyone appreciates a human interaction, and even the toughest personality can be cracked with a smile and some persistence. In the end, it is the human interactions and the open and honest communication that not only make us better healthcare providers but happier and healthier human beings.
David Fetzer, MD, is an assistant professor in the Abdominal Imaging Division, as well as is the Medical Director of Ultrasound in the Department of Radiology at the UT Southwestern Medical Center.
Interested in reading more about communication? Check out the following posts from the Scan:
The Scan has been a home for all things ultrasound, from accreditation to zoos, since its debut 5 years ago, on February 6, 2015.
In its first 5 years, the Scan has seen exponential growth, in large part due to the hard work of our 110 writers, who have volunteered their time to provide the 134 posts that are available on this anniversary. And it all began with Why Not Start? by Peter Magnuson, the AIUM’s Director of Communications and Member Services, who spearheaded the blog’s development.
In honor of this 5th Anniversary, here are some of your favorites:
Bus 22 from Stanford to Pacific Free Clinic (PFC) – 1.5 hours. Bus 22 and 25 from PFC to Santa Clara Valley Medical Center – 1 hour. Bus 70 from PFC to Foothill Family Community Clinic – 30 minutes. Bus 70 and 26 from PFC to Community Health Partnership – 30 minutes. Without a car, I managed the PFC and networked with community clinics and hospitals by bus. These bus rides provided me with a glimpse of one barrier disadvantaged patients endure in order to access the healthcare system. If my weekly navigation of San Jose’s health care system has been one long bus ride, so too has my medical training–a long seamless journey of exploring three vital components of medicine: community service to the underserved, translational/epidemiologic research, and internal medicine.
As stated in the opening of my personal statement for residency application (above) community service was one of my main motivations to go into internal medicine. Yet, despite 7 years of volunteering and managing 3 free clinics in 3 cities, I became focused on developing clinical skills and establishing an academic career instead. I pushed community service aside during my residency training and beyond until my trip to Gros-Morne, Haiti, where I, together with Atria Connect (https://www.atriaconnect.org), taught point-of-care ultrasound (POCUS).
Through Atria Connect, 14 other physicians from around the world and I trained 12 Haitian physicians at Hospital Alma Mater, where there were no echocardiograms, CT imaging, or MRI. There were 2 diagnostic imaging modalities available: a nonfunctional x-ray machine and an ancient ultrasound machine with just a transvaginal probe. For 3 months, we rotated weekly to provide hands-on training in a longitudinal POCUS curriculum that combined flipped classroom learning with online modules, onsite hands-on teaching (Picture 1), and remote hands-on training via a tele-ultrasound platform. At the end of the curriculum, the 2 youngest Haitian physicians then spearheaded a longitudinal training program for the remaining clinical staff within the hospital.
Picture 1. Left to Right: Dr. Bruno Exame (Haiti), Dr. Ricardo Henri (Haiti), Dr. Jesper Danielson (Sweden), Dr. Michel Hugues (Haiti). Dr. Hugues, the Chief Medical Officer of Hospital Alma Mater, is shown performing focused cardiac ultrasound under the guidance of Dr. Danielson and Dr. Henri. Dr. Exame was evaluating the quality of the ultrasound image.
Similar to many global health efforts with POCUS, the 15 trainers, including myself, and the Haitian physicians experienced an evolution in clinical care. It ranged from expedited diagnoses of tuberculosis through the FASH protocol (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3554543/) to an unexpected evaluation of left heart failure possibly due to thiamine deficiency, to immediate trauma triages of patients from motor vehicle accidents in a town where traffic laws do not exist. With POCUS, Haitians have access to diagnostic medicine that would otherwise be denied in rural Haiti, where it would take a 4-hour bus/motorcycle ride on unpaved road to obtain. The evolution went beyond clinical management and access to basic health care, however.
Besides transforming medicine in resource-low settings, POCUS rekindled my initial drive to go into internal medicine: community service for the underserved. It empowers me to serve more effectively by training providers with an innovative technology of sustainable impact. With a tele-ultrasound platform and WhatsApp, POCUS draws me closer to the underserved in remote places, thus expanding community service on to a global scale, onsite and offsite.
More importantly, POCUS loops me back to community service at the local level, the original start of my journey to internal medicine. Similar to the Haitians in Gros-Morne, the disadvantaged in the United States face obstacles in which an additional trip to basic diagnostic radiology or cardiology, other than limited outpatient medicine encounters, proves to be difficult. An expedited evaluation with POCUS for simple clinical questions can maximize diagnostic capability and further advance clinical care as a way of improving access in this vulnerable population.
One instance in which I had a missed opportunity was during my residency in expediting care for my favorite clinic patient at an urban health clinic. She, unfortunately, suffered from multi-organ manifestations of sarcoidosis. One day, she presented with an acute onset of dyspnea and chest pain without hypoxia. Her examination was not significant for volume overload, pneumonia, or reactive airway disease. Her breath sound was mildly reduced on the right side. A chest X-ray was ordered. However, due to transportation cost and her inability to take off additional time from work, she did not obtain a chest X-ray until 3 days later. Her chest X-ray showed a spontaneous pneumothorax of 8 cm in size due to structural lung changes from her sarcoidosis. She was immediately sent to the emergency room for pigtail placement. Had I learned lung ultrasound, an immediate diagnosis would have been made and her care would be further advanced at minimal cost. While POCUS benefits all patients, POCUS magnifies the impact for the underserved by overcoming socioeconomic barriers.
Picture 2. Left to Right: Dr. Michel Hugues (Haiti), Dr. Bruno Exame (Haiti), Dr. Jesper Danielson (Sweden), Dr. Gigi Liu (United States), Dr. Ricardo Henri (Haiti), and Dr. Josue Bouloute (Haiti) on the last day of the 4-month POCUS training.
My life-changing trip to Gros-Morne, Haiti (Picture 2), expanded my global awareness and revived my sense of social responsibility through community service locally, regionally, nationally, and internationally. This is the essence of global citizenship (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726429/?report=reader; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6076566/?report=reader). Instead of just providing much-needed medical care to the underserved, POCUS empowers providers to be a more effective global citizen by expediting diagnosis and care efficiently and cost-effectively. It has been a privilege to be trained as a physician and be taught by amazing mentors with life-saving POCUS skills. As a global citizen, I vow to train health care workers on POCUS on multiple geographic levels as part of my social mission to improve access and care for the disadvantaged, even if this requires a very long bus ride…
How has POCUS changed your practice? What do you do to be a global citizen? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.
Dr. Gigi Liu, MD, MSc, FACP, is a hospitalist and proceduralist at Johns Hopkins Hospital who leads the POCUS curriculum for Osler Internal Medicine Residency program and Johns Hopkins Bayview Internal Medicine Residency program.
The subtle sound of a distant explosion rang out. We barely flinched, numb to the sound that was a near-daily occurrence at our remote outpost in war-torn Afghanistan in 2005. Minutes later, a fast-approaching Humvee suggested that this time, something was amiss. The sight of a bloodied soldier draped over the vehicle’s hood provided confirmation.
CPT Jonathan Monti, left, and Lt. Col. Robert Craig, in the army physical training shirt, treat a trauma casualty at Forward Operating Base Ripley in 20005.
As we scrambled to prepare our dusty, sparsely equipped treatment tent, casualties poured through the door. A young Afghan man, triaged as minimally injured, lay in front of me, peppered from head to toe with small shrapnel wounds. His wounds were indeed benign-appearing, as his triage category suggested, but penetrating wounds can be deceptive. I struggled to gauge whether his lack of responsiveness to my questions was due to our language barrier, or something more sinister like blunt or penetrating head trauma. His primary survey was otherwise unremarkable…nosignificant external hemorrhage, airway intact without labored breathing. His blood pressure was borderline low, not an uncommon finding in the thin/healthy.
I dusted off the nearby SonoSite 180, now widely considered to be the first portable ultrasound device of its kind. Most of its knobs were still foreign to me, and my inexperienced eyes struggled to interpret the grainy images. His belly and lungs appeared unremarkable, but scanning through his subxiphoid region, the black stripe encircling his heart jumped out at me, inconsistent with my already-anchoring bias of a traumatic brain injury, but consistent with the images I had only seen in Ma and Mateer’s landmark text.
I quickly called the surgeon, whose experience with the device barely surpassed my own. After a quick look at both the machine and text, he commanded his team to prep the operating suite, an equally dusty, adjacent tent. Minutes later, the surgeon’s skillful incision of the patient’s pericardium evacuated the now-tamponading bloody effusion, revealing the tiny piece of shrapnel embedded within the patient’s right ventricular wall and saving the patient’s life.
On that day, the humbling and lifesaving power of point-of-care ultrasound (POCUS) was revealed to me. As a junior clinician with limited trauma experience, I had no formal ultrasound training, mentorship, or experience. Yet this machine, when coupled with only a book, and the desire to learn, allowed me the opportunity to overcome the shortcomings of my physical exam skills, my resource constraints, and my cognitive bias, and the mistriage of another, to ensure a patient received the timely and definitive care he deserved. In the decade or so since, I have been fortunate to serve my patients while under the tutelage of several POCUS experts whose altruistic and thoughtful mentorship allowed me the opportunity to cultivate my passion for this powerful tool, while also imparting the nuances and limitations of POCUS, frequently leading me back to a common question:
“How can we best harness the full power of POCUS?”
There is a rapidly growing body of evidence that suggests that clinicians of various skill levels can effectively employ focused POCUS applications with minimal training. Though not without risk, POCUS is no different from other clinical skills; performed with variable competency regardless of profession, specialty, or scope of practice. Some will evoke the mantra of “a fool with a tool is still a fool,” which may certainly be true, but it is unfair to assume that foolhardiness is necessarily bound by profession, experience, or even breadth/depth of training.
The notion that POCUS can/should only be monolithically employed by a limited number of broadly/extensively trained physicians may be yet another example of the monoculture of thought that continues to plague our healthcare system. Certainly, any diagnostic testing should be performed thoughtfully; but do we limit who can use the stethoscope, or order a CBC, based upon title or his/her knowledge of Bayesian principles, Fagan’s nomogram, or pre/post-test probabilities and test-characteristics? Do all successful clinicians adhere to these principles with each and every test they order? Are there other factors to consider when ordering diagnostic testing, particularly in the resource-constrained areas where POCUS can have the greatest impact?
Until POCUS is adaptably and appropriately employed by all those who provide care, regardless of practice setting and scope, its full benefit and potential, especially to those living in medically underserved areas, cannot be realized. Some will inevitably oppose this concept, citing concerns with expertise, patient safety, documentation, reimbursement, etc. Ironically, it is these same arguments that emergency physicians faced 2 decades ago before successfully overcoming significant resistance to fully integrate POCUS into emergency medicine practice.
POCUS is a rare technological tool; one that is portable, versatile, and liked by both patients and clinicians alike. It can expedite diagnosis and care, improve the accuracy of our physical exam, and help us overcome our own anchoring bias while reducing the risk of procedural error, healthcare cost, and iatrogenic radiation exposure. Though it may not impact a majority of patients, for those it does, that impact is often significant. But the most uniquely promising characteristic of POCUS that we should all embrace is its ability to bring better-informed clinicians of any ilk, back to the bedside where they belong, wherever those in need of care may be.
Do you believe the democratization of point-of-care ultrasound can enhance patient care? Share with us your thoughts or your efforts to do so: comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.
Dedicated to the memory of CPT Jeremy A. Chandler, 1st BN, 3rd Special Forces Group, whose life was lost while bravely serving his country on that fateful day, August11th, 2005, in Tarin Kowt, Afghanistan. https://www.greenberetfoundation.org/memorial/jeremy-a-chandler/
Jonathan Monti, PA-C, RDMS, is an Associate Professor of Emergency Medicine PA Studies at Baylor University and president of the Society of Point-of-Care Ultrasound (SPOCUS). He is currently conducting research on the unconventional employment of ultrasound in the U.S. Armed Forces as an employee of the Henry M. Jackson Foundation for the Advancement of Military Medicine.
“A pregnancy test and a dip urine,” Dr. St. Louis responded. “Wow!” I replied in surprise. Having completed a fellowship in global health, I had learned that testing was severely limited in resource-limited settings, particularly outside of normal business hours. This was still impressive. We had just been discussing how things were going with his new job at Princess Alice Hospital and what tests were available overnight in his workplace that is located in the eastern mountains of Grenada. During weekday daytime hours, imaging is limited to plain film x-ray. Occasionally, there is an ultrasound technician also available. If desperate, the technicians can be called in from home. All other tests: blood, urine, CSF, must be batched and sent by car via a winding, serpiginous road over a mountain to the capital. If they’re lucky, you may get the test result in about 6 hours; however, most take up to 12 hours. Most advanced imaging, CT and MRI, are only available in the private sector.
I first met Dr. Daniel St. Louis just a few weeks after beginning the Masters of Emergency Medicine program offered by the University of Guyana and started with the help of Emergency Medicine faculty and Vanderbilt University. With other emergency medicine colleagues, I had spent a lot of time helping him learn to perform, interpret, and apply point-of-care ultrasound studies during his training in the Accident and Emergency Department at Georgetown Public Hospital before he returned to his native island in the south Caribbean. Dr. St. Louis immediately saw the benefit of ultrasound during his training and requested every piece of material possible to be able to master sonography.
The care that Daniel and his colleagues provide with limited testing is really impressive. But of all tests that Dr. St. Louis could be equipped with while caring for a sick patient on an overnight shift, ultrasound is uniquely valuable. Bedside ultrasound doesn’t require a technician, it is reusable, it is versatile, it provides rapid diagnosis of many critical illnesses, and it provides the diagnosis to actionable diseases where lives hang in the balance of the minutes and hours ultrasound saves. There are more significant tests: a microscope and Giemsa stain in a malaria endemic zone or rapid HIV testing at the national public health level. But when I was standing in front of a child in shock from shrapnel wounds outside Mosul, Iraq, an ultrasound probe is what I want most.
As bedside ultrasound machines continue to become more portable and more affordable, the significance of bedside ultrasound will continue to grow. This is true in a large academic tertiary medical center, in regional access hospitals in Grenada, and in critical access health posts in the most remote regions of the globe. AIUM and its members are uniquely positioned to aid in providing equipment and, more importantly, providing education and techniques to help improve the quality of bedside ultrasound as one of the most important clinical tests worldwide. Will we be up for the challenge?
If you work in a resource-limited setting, how is ultrasound most useful for you? How have you seen ultrasound incorporated into medical care in other nations? Comment below or let us know on Twitter: @AIUM_Ultrasound.
Jordan Rupp, MD, RDMS, is an Assistant Professor of Emergency Medicine at Vanderbilt University Medical Center and the Director for Global Sounds: Ultrasound Development Project. Read more about Global Sounds at www.globalsoundsproject.org or continue the conversation on Twitter: @globalsounds_us.
Did you know that blood can only be stored for up to 6 weeks when refrigerated? Because synthetic blood is not available in the clinic, blood supplies must be continually replenished from healthy donors. Even if there is a surge in blood donations at one point in time, 6 weeks later there could be shortages if continued donations do not meet the current demand. Blood can be frozen for a decade or more but significant challenges in processing blood for frozen storage limit this option to specific situations such as for rare blood types or military use. The freezing process currently utilizes high concentrations of glycerol to protect red blood cells during frozen storage but this compound must be removed prior to transfusion, and the de-glycerolization process is very sensitive and time-consuming. Therefore, most hospitals and medical centers utilize refrigeration for blood storage.
What if, instead of refrigerating or freezing blood, there was a method to freeze-dry blood for long-term storage as a dry powder, similar to the process used for astronaut food? This could enable long-term blood storage at room temperature, and when the blood is needed for transfusion the cells could be quickly reconstituted simply by adding sterile water. Not only would this offer another option for long-term storage, it would be particularly useful in situations where refrigeration or freezing is not available, such as in some remote medical centers or for the military in far-forward settings. In addition, this method could enable stockpiles of strategic blood reserves in order to maintain an adequate blood supply during disasters such as hurricanes, which disrupt blood donations.
Electron microscopy image of red blood cells after drying/rehydration following ultrasound-mediated loading with preservative compounds.
The idea of turning blood into a dry powder and then rehydrating it for transfusion may sound like science fiction, but could it become a reality? Can nature provide clues to help us solve this problem? There are many cases in history where significant scientific breakthroughs were achieved by studying nature. For example, the Wright brothers studied the characteristics of birds’ wings during flight to discover an effective design for airplane wings. Also, Alessandro Volta invented the battery after carefully studying the electric organ in torpedo fish. In the context of cell preservation, it has been found that some organisms can survive complete desiccation for long periods of time. For example, tardigrades and brine shrimp (“water bears” and “sea monkeys”) can be dried out and remain in a state that approaches “suspended animation” for decades, but when they are rehydrated they return to normal physiological function and can even reproduce. This led us to ask the question, if these complex multicellular animals can survive desiccation, why not individual red blood cells? Scientists have found that these organisms produce protective compounds, including certain sugars and proteins, which prevent damage to their membranes during drying and rehydration.
Unfortunately, human cells do not have the transporters in their membranes that enable internalization of the protective compounds found in organisms that can survive desiccation. Therefore, an active loading method is required. We realized that the process of ultrasound-mediated drug delivery via sonoporation could potentially be applied to solve this problem and enable delivery of protective compounds into human red blood cells. In the past, most ultrasound research has either ignored red blood cells or attempted to minimize sonoporation in these cells. But what if we could intentionally sonoporate red blood cells outside of the body in order to actively load them with protective compounds so that they could be stored as a dry powder at room temperature until needed for transfusion?
Our initial efforts to load red blood cells with protective compounds for storage as a dry powder have been promising. We prepared solutions containing red blood cells, preservative compounds, and microbubbles followed by treatment with B-mode ultrasound for ~60 seconds. After ultrasound treatment, the cells were freeze-dried and stored as a dried powder at room temperature (21–23 °C) for 6 weeks or longer. Cells were rehydrated with water and we measured up to 30% recovery of viable red blood cells. In addition, we performed electron microscopy imaging of the rehydrated red blood cells and observed evidence of normal biconcave-discoid shape. Our next steps involve testing the rehydrated cells in an animal model of acute hemorrhage in order to assess the function and safety of the red blood cells in vivo after dry storage at room temperature.
Research studies are currently ongoing and much more work remains to be done before clinical translation is possible, but if it is successful this approach could have a significant impact on blood supply, particularly in locations where refrigeration and freezing are not available. In addition, this approach could potentially enable dry storage of other cell products. As I consider the possibilities of this approach, I wonder if there are other things that we can learn from nature that could also transform medical practice.
Have you learned something else from nature that has been incorporated into your medical practice? Do you have any ideas that could potentially transform medical practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.
Jonathan Kopechek is an Assistant Professor of Bioengineering at the University of Louisville. His Twitter handle is @ProfKope.
2. 
3. 
4. 
5. 
