Tag Archives: low-resource

What if Ultraportable Ultrasound Devices Were the Future of Healthcare in Africa?

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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:

        Where it Matters Most

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        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:

        Do More With Less: Ultrasound

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        Life is not always easy, sometimes you just have to manage with what you have. To work with limited resources is one of the skills you acquire once you are a primary care physician and particularly in Africa.

        This is also true concerning point-of-care ultrasound (POCUS); it is possible to do more with less. If you really understand how it works, you can find new ways to use your tools to get the correct diagnosis.

        Now, I want to share with you the case of a 53-year-old male patient whose major complaint was joint pains, particularly in the left wrist and knee. Upon physical examination, the joints were warm, swollen, and painful. I hypothesized that the diagnosis was a primary gout episode but in my health facility I don’t have a uric acid test that I would ordinarily use for confirmation of the diagnosis. I then performed a POCUS examination to confirm the diagnosis by looking for the double contour cartilage line, which is a sign of gout in joints due to uric acid deposit at the surface of bone cartilage. I didn’t have a linear high-frequency probe, so I used an endocavitary probe just as you can see in the pictures.

        Ultrasound images of the knee showing the double contour sign indicative of gout.

        POCUS can greatly increase healthcare in low-income countries. Usually, the healthcare gap between upper-income and low-income countries is huge but, with POCUS, the same technics can be applied to both, with the same results, if ultrasound devices are available.

        However, the problem remains that there is a lack of healthcare professionals who are skilled enough to use it and teach others. The problem is no longer an absence of devices but is now due to an absence of knowledge of how to use them.

        Fortunately, due to COVID-19 lockdowns, we know almost everything that can be taught online. Therefore, it is time for us to think about establishing a new way to teach, learn, and practice ultrasound. Many ultrasound societies, such as the AIUM, ISUOG, and EDE, have started to share free POCUS education on their websites. Free online courses should be encouraged since they will lead us to the democratization of ultrasound, particularly in low-resource settings.

        Yannick Ndefo, MD, is a general practitioner at St Thomas hospital in Douala, Cameroon.

        Interested in learning more? Check out the following posts from the Scan:

        No Words Are Strong Enough

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        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.

        IMG_20200513_125259_B

        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. IMG_20200513_100229

        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: