New global ultrasound POCUS is no hocus

How can one treat a disease or condition if one can’t diagnose it? This fundamental challenge confronts doctors in places without easy access to technology. Fortunately, medical technology is advancing—and when it comes to ultrasound devices, the future of inexpensive portable technology is now.

Yale School of Medicine (YSM) faculty, residents, and students are engaged with point-of-care ultrasound (POCUS) initiatives far from the Yale campus, such as in Chile, the Dominican Republic, Rwanda, and Uganda. With its portability and immediacy, POCUS is a powerful diagnostic tool, which can also enhance medical education, both on campus, and worldwide.

Christopher L. Moore, MD, associate professor of emergency medicine and chief of the section of emergency ultrasound, was first exposed to POCUS during residency in 1998, and realized it could be a powerful diagnostic tool in resource-constrained settings. While traveling to Nicaragua on a medical mission trip as a third-year resident, he thought “it would be incredible” if he could incorporate ultrasound into the mission. He mentioned this to a company, Sonosite, that had developed a portable ultrasound machine, and to his surprise “on the morning of my flight a package showed up on my front door.”

Moore and colleagues scanned several hundred people in a month and while the quality of the images was poor compared to what is possible today, they “found some serious pathology that would not have been possible to find without ultrasound.” The detail provided the justification needed to fly individuals to a hospital in Managua. This convinced Moore “of the powerful potential impact this technology could have and reinforced my commitment to learn it thoroughly.”

For Moore, “the adage that it is more important to teach a man to fish than to give him a fish” applies to ultrasound. “If you are well trained and traveling with ultrasound equipment you can make a small difference, but if you can create a situation where the medical practitioners really understand what they are doing and can continue to use and train others that is what is really self-sustaining.” Moore is creating free web-based tutorials on POCUS, to supplement onsite global training efforts.

A number of Yale Emergency Medicine residents have focused on building global POCUS capacity, by increasing access to equipment, and strengthening skills to use and train others on the equipment. In April 2019, EM residents Matt James and Charles Duke were in Kampala, Uganda through the Yale/Stanford Johnson & Johnson Global Health Scholars Program (J&J Program). They were at Mulago Hospital, the national referral center for trauma, where residents and interns did not routinely have access to an ultrasound machine. Rather, when a patient needed an ultrasound, it was formally ordered, the patient was placed in a queue, and a radiologist performed the test.

Duke and James worked with a senior surgical resident at the hospital to make an ultrasound machine available at all times. As Duke explains, “ultrasound allows immediate visualization of life-threatening bleeding within a patient’s abdomen and chest. Recognizing this earlier can have a huge impact on the survivability of a major injury.” He continued, “I am hoping that our impact here will be to impart the importance of timely ultrasound evaluations in emergency department patients,” adding that some residents are “interested in pursuing funding to obtain portable ultrasounds for themselves so that they can make this a part of their practice long-term.”

Rachel Solnick, who just completed her fourth year as an EM resident, also participated in the J&J Program in Kampala. She notes that in addition to cost, “the logistics of access to new technology and integration into the curriculum is another challenge.” She hopes “that in seeing the diagnostic potential of point-of-care ultrasound, international trainees in front line fields like trauma surgery and emergency medicine will advocate that their health systems prioritize training physicians to use this technology.”

For three years, Rachel Liu, MBBCh, BAO, assistant professor of emergency medicine and director of point-of-care ultrasound education, traveled annually to Pontifica Universidad Catolica de Chile to build POCUS capacity, but then “saw that they had become competent, and we became no longer needed. This was remarkable to me because the first year, they definitely were at novice level.”

Liu notes that specialties across YSM, in addition to EM, lead programs and educational trips with a POCUS component, citing Ob/Gyn, surgery, cardiology, internal medicine, and radiology as some examples.

Urania Magriples, MD, associate professor of obstetrics, gynecology, and reproductive sciences, has been involved in training in Ob/Gyn, including ultrasound, in Rwanda since 2010, through the Human Resources for Health Program. She typically spends two to three months a year there. Magriples engages in “hand-on training with the residents and medical students daily on rounds and in admission, so that every patient has multiple ultrasounds for training whether it is OB or GYN. We scan everything that can be scanned.” She recently had a handheld ultrasound with her, enabling POCUS on every patient. “Point-of-care ultrasound there is crucial because getting an ‘official’ one can be difficult.” She adds that once the program trained the first class of Rwandan residents, they were hired as faculty.

Starting in 2009, France Galerneau, MD, associate professor of obstetrics, gynecology, and reproductive sciences, and former YSM faculty member Lisa Walke, MD, traveled to the Dominican Republic (DR), initially working with Good Samaritan Hospital in La Romana, and then, beginning in 2013, with Instituto Tecnologico de Santo Domingo (INTEC), when they started an annual week-long elective. While the elective’s focus is on topics other than POCUS, such as the DR health care and medical education system, and delivery of primary care services in internal medicine, Ob/Gyn, and pediatrics, Galerneau always has brought an ultrasound machine to the DR to use for Ob/Gyn patient care and medical education purposes.

This year, two of the faculty who joined the INTEC trip, Jaideep Talwalkar, MD, associate professor of medicine and director of clinical skills, and Yulanka Castro-Dominguez, MD, clinical fellow, each also brought portable ultrasound equipment, making three machines available to the group for patient care and training. Talwalkar describes how “the quick and easy access to ultrasound seemed even more important in this resource-limited setting where access to other types of imaging is less readily available.”

Olamide Olawoyin, class of 2022, one of the eight YSM students on the trip, found the portability of the butterfly probe, which can fit in one’s pocket, “so fascinating.” (Moore describes this probe, which connects to an iPhone and costs about $2,000, as “a potential game changer.”) For Olawoyin, the week’s highlight was showing a 33-weeks pregnant woman ultrasound images of her baby, including the heart. Olawoyin believes ultrasound results in more patient-centered care, because it enables patients to see and understand what is happening with their own bodies.

Moore notes factors that make POCUS beneficial also make it attractive across a geographically divergent audience: “Ultrasound is pretty unique among medical imaging technologies in being able to immediately see real time images without using any radiation simply by putting the probe in someone’s hand. This is very powerful. People immediately grasp this and are very eager to learn it and use it.”