POCUS: My Path to Be an Effective Global Citizen

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.

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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.

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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.

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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.

 

 

 

 

 

Sonography and the Seeds of Education in Underserved Rural Clinics

How many of us began our sonography journey thinking about the number of callbacks that we would log per shift, the number of patients that we would scan in an 8-hour day, or, even worse, the number of career-ending ailments that we would amass? Zero; we didn’t. tammySterns_2017

We saw ultrasound as a way to contribute to something bigger than ourselves.

The complex, yet simplistic, science of sound drew us to the field. Looking at the screen and seeing the images come to life was fascinating, and being the first to see presenting pathology while shedding light on the diagnosis mesmerized us. The thought that even after 20 or 30 years in the profession we would encounter images of structures that we’d never seen before was enticing, and the opportunity to be a life-long leaner was thrilling.

Patient interaction and our role in their medical experience appealed to us. Not too much, not too little, but just the right amount of patient care time that allowed us to interact with them and leave a positive imprint on their journey. We imagined we would sit by their bedsides, walk them casually back to the exam rooms, and listen as they shared.

Our patients would come first.

Instead, too often, we found ourselves in the middle of a never-ending battle between cost-effectiveness and patient satisfaction reports. We logged more hours of callbacks than we ever thought possible, sometimes having difficulty even finding the correct key to open the ultrasound office door. We strived to create the profession that we had imagined within the confines of the variables that we’d been given. We did the best that we could, often to the detriment of our own bodies.

And, somewhere along the way, we forgot the wonder of our profession.

About 10 years ago, I had the opportunity to participate in my first overseas medical trip. A group of physicians and a few sonographers, with portable machines strapped in backpacks, were intent on sharing sonography with some of our peers an ocean away. It was during this trip that I saw the purest form of ultrasound come to life. We had one of the simplest of machines and the most basic of lectures and yet they came from miles to learn. The patients sat all day in the heat waiting for the opportunity to have an ultrasound scan. I witnessed ultrasound identifying and explaining pain that had existed for years. I saw tears of relief, joy, and despair as people received answers that changed their lives.

A few years later, I was able to return to the same place. I fully expected to find that they had not utilized our lessons on sonography to their fullest. Instead, our previous pupils greeted us with dog-eared textbooks, mastered skills, and the desire to know more! The seeds of education that we had planted had flourished as they realized the potential ultrasound held for their rural clinics. It offered the ability to quickly investigate and diagnose and you could see the wonder of ultrasound that we had once experienced reflected in their eyes.

Seven years ago, my family and I had the opportunity to move to a developing country. Living in the second-poorest country in the western hemisphere with limited medical availability, I now see every day the wonder of our profession come to life. All the benefits of ultrasound that we learned as students, that are often taken for granted, are the benefits that allow lives to be changed every day.

Portability – I can scan in a makeshift clinic, under a tree in a field, or in someone’s handmade shelter while they lay on the floor.

Inexpensive – Portable machines are relatively inexpensive and diagnostically sound, making them perfect for short-term trips or as gifts to native physicians.

Quick – Within minutes, we can scan and find answers to problems that have hindered the livelihood of those who are sick and in pain. One of my first patients was an OB patient who had been in labor for several days without any progress. A quick scan revealed placenta previa.

Relatively Safe – Without the worry of radiation and chemicals, ultrasound, when utilized by those who are qualified, provides a safe method of imaging.

True, my exam room isn’t exactly ergonomically correct and there are times that chickens and roosters run underfoot. I’ve had to prop the machine on a rock and scan in the brightest sun of the day. But I’ve also witnessed a mother’s face when she sees her baby for the very first time without me having to operate under the time constraints of efficiency. I’ve held a father’s hand as he realized that the pain he’s had for years isn’t the cancer he so greatly feared but a simple fix. I’ve scanned at the bedside of a daughter who lay dying without any medical options, and I fall more and more in love with our profession every single day.

Experience the wonder of ultrasound again.

If given the opportunity, I encourage you to participate in a medically related trip or volunteer opportunity. You will see firsthand how our profession and our images impact the world one life and one scan at a time. You don’t have to move permanently as we did to a developing country. Opportunities also abound in your local community from volunteering your time as a clinical instructor to scanning for local centers. Expand your horizons and allow yourself to experience the wonder of ultrasound again.

 

How have you seen ultrasound incorporated into medical care in other nations? Do you have an ultrasound story to tell? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Tammy Stearns, MS, RT(R), RDMS, RVT, FSDMS, is Director of Women’s Ministry and Sonographer for Project H.O.P.E. in Managua, Nicaragua. She is also the President of the Society of Diagnostic Medical Sonography and an adjunct professor of Diagnostic Medical Sonography at Adventist University in Orlando, Florida, and a sonographer consultant for Heartbeat International.  She is also the author of “Know Hope” and “Living Worthy”.