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Racism is a Public Health Crisis

The brutal murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and the countless others before them are a result of brutality that has been and still is perpetuated by a culture of white supremacy and racist violence towards Black people. These are not one-time incidents by rogue police officers or vigilantes, but rather the direct consequence of a structurally racist system that has treated Black lives as enemies.

The events of the past few weeks have caused us to reflect on ourselves as individuals, our privilege, our organization, our industry, and where we go from here. We acknowledge that racism is an ongoing public health crisis. It is a consequence of a structurally racist system that is failing people of color every day. This is readily apparent not only in the police brutality that disproportionately effects Black Americans, but also in the history of slavery and discrimination that can be seen today in many social determinants of health. While the COVID-19 pandemic has laid these inequities bare for all Americans to see, the underlying injustices have endured for generations.

As an organization, Global Emergency Care continues to be committed to strengthening the emergency care workforce capacity in Uganda and expanding the cadre of national clinical and research emergency medicine experts. We focus on local advocacy, and leveraging our privilege to amplify the Ugandan voice. Our vision is to be a part of building an emergency care system that is designed, implemented, and led by Ugandans for Ugandans. 

We continue to be committed to demonstrate reciprocity to support the work of the leading Ugandan institutions in the quest to build a sustainable emergency care system. We strive to be a catalyst to reduce the unequal power dynamics between the global north and south by trying to build capacity, lead from behind, and do our best to listen and learn. Moving forward, we commit to inclusivity and to be enablers of our Ugandan colleagues in capacity development, academic research, and advocacy. 

We work in Uganda where our staff on the ground is 100% Ugandan, but as global health practitioners, we recognize the enduring legacy of colonialism and structural racism in global health. We acknowledge the unequal power dynamics: racism, classism, and many of the residual exploitations of a terrible colonial past, while at the same time must commit to not engage in a neocolonial narrative. Today, we continue to commit to do our part to decolonize global health.

As Seye Ambimbola eloquently put it, “We can begin to truly decolonize global health by being aware of what we do not know, that people understand their own lives better than we could ever do, that they and only they can truly improve their own circumstances and that those of us who work in global health are only, at best, enablers.”

We have much work to do. In particular, those of us who are white must continually reckon with our privilege and take actions to enact a power shift. We need to have hard conversations, challenge our assumptions, cultivate empathy, and actively pursue an anti-racist, anti-colonialist agenda. 

We do not yet have the answers of how we will implement these changes, but we are committed to this work and will keep all of you – our friends, families, supporters, and partners – updated as we do the necessary work. Thank you for fighting for a more equitable world with us.

In humility, commitment, and solidarity,

Mark Bisanzo, MD, DTM&H, FACEP 
President of the Board of Directors

Heather Hammerstedt, MD, MPH, FACEP
Board of Directors

Stacey Chamberlain, MD, MPH
Board of Directors

Bradley Dreifuss, MD
Board of Directors

Tom Neill, MPH, MBA
Executive Director

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Fighting COVID-19 in the US and Uganda

The COVID-19 Treatment Team at Masaka Hospital

Patient volume in the ED – Fear of contracting COVID-19

In the US, Emergency Department (ED) patient volumes have been 40-50% lower than normal over the last month at University of Maryland Medical Center. Decreased travel and recreation have greatly reduced the number of injuries. Moreover, fear of contracting Coronavirus at the ED or hospital is also impacting patients seeking care even when they are ill. 

In Uganda, Emergency Care Practitioners (ECPs) working on the front lines of the COVID-19 response in Uganda are seeing a similar decrease in ED patient volume, but the patients coming to the ED are much sicker. Part of the Ugandan government’s COVID-19 response has been to restrict public transportation, especially by boda boda, motorcycle taxis that are prolific across Uganda, in an effort to decrease virus transmissions. Decreased traffic has reduced injuries from road traffic accidents seen in the ED, but there is concern seeing more patients presenting with injuries sustained in episodes of interpersonal violence, especially within the home. Similar to the US, our ECPs are worried about violence with families quarantining at home in a time of increased stress.

Furthermore, economic concerns stemming from the COVID-19 shutdown have increased poverty, further limiting patients’ resources for seeking healthcare. Charles: “Patients are not afraid to come to ED because of COVID-19, simply because we haven’t got any COVID-19 cases in western Uganda, but they are not coming simply because of the measures put in place by the government to stop the spread of the virus.”

Providing care during COVID-19 and effects on the quality of care

In the US, social distancing is an effort to “flatten the curve” and ensure that the healthcare system does not become overwhelmed. However, working in the ED in the US and following medical pieces in the popular literature, it is clear that COVID-19 is impacting care in many smaller ways like: provider concerns about contracting the virus through patient contacts; limited personal protective equipment leading to decreased face to face patient contacts; and delays related to COVID-19  testing and canceled non-essential appointments or surgeries.

In Uganda, the healthcare system is facing the same challenges compounded by baseline resource constraints. Charles Ndyamwijuka, GEC’s Operations Manager, expresses the concerns of those working on the front lines of the response Uganda, “with the department grappling with limited PPE and no testing, there is fear that ED staff is at risk of contracting COVID-19 since they are the face of the hospital.”

Benifer Niwagaba, an Emergency Care Practitioner based at Nyakibale Hospital said, “people are no longer working and businesses are closed. There is not enough money to care for their families and they can’t make it to hospital with no money. A few weeks back I treated a patient with a diabetic emergency who had spent two days in a low resource facility where they couldn’t diagnosis his condition due to lack of funds and transport.”

Charles adds, “now, many patients that come to the ED are very sick which is challenging for the ED staff. Patients are going to the nearest clinic, or self-medicating, because of both limited transport and limited financial resources to come to ED. In the era of COVID-19, patients exhaust all the other options and the ED becomes the last resort.”

Testing

In the US, limited testing, as well as concerns about test accuracy, has been a challenge in addressing the pandemic. In rural Uganda, our teams are providing care with virtually no access to testing, leading to concerns that they will not be able to identify patients with COVID-19 to provide high quality care, but also to keep themselves and other patients safe from the disease. The government is providing testing; however, it is offered at a site near the capital (Entebbe) hours from where GEC works. Confirmed cases are being cared for by the government referral hospitals so the ECPs are working hard to identify cases through symptoms. Still without testing the fear of missing cases is significant since the symptoms of COVID-19 are vague and can mimic many other diseases.

Protecting our families

Front line healthcare workers everywhere are concerned about bringing COVID-19  home to their families and are taking every precaution to reduce the risk to their loved ones. Our colleagues in Uganda are no different in their concerns: “I am staying somewhere else away from family, but even though I stay away from my family I know that everyone is a potential victim” (Charles). For those who are still living with their families the situation can be more difficult since they dispose of masks and wash their hands at the hospital, but go home in uniform. Changes of clothes and opportunities to do laundry are also more limited.

Overall, the COVID-19 pandemic is showing similarities around the globe. From health systems with many resources to those that are under-resourced, the commonalities bring us all closer together. Uganda has done an excellent job in its surveillance, contact tracing, and isolation leading to relatively few number of cases to date. Whereas, the US response has shown a clear lack of coordination, planning, and a fragmented execution. Unfortunately, front line health workers everywhere are putting their lives and sometimes their families’ lives on the line, to fight this global pandemic. We salute to courage and bravery of all front line health workers risking their lives to protect all of us.

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True Stories of Mothers Fighting COVID-19

As we appreciate and give thanks to our mothers around the globe, I want to take this opportunity to highlight some of the extraordinary mothers working on the front lines of this pandemic.

Life has been turned upside down for the mothers working in hospitals overwhelmed by COVID-19 patients. The days of coming home to hugs and kisses from their children are gone. In its place, is a strict regimen of changing clothes, sterilizing everything, and fearful hugs with the constant, nagging fear of infecting loved ones.

Fear for our families

Heather Hammerstedt, emergency physician and GEC co-founder working night shifts in an emergency department, said her worry is constant. 

“When I get home, I change and everything goes directly into the laundry and I shower again. Only then do I risk spending time with my children, but always in fear of getting them sick. I worry about myself getting sick and dying; about my husband getting sick from me and dying; about the effect of my stress on my children; about their education during this time.”

Our colleagues in Uganda echoed this sentiment. Elizabeth is an ECP working in the emergency department in Masaka. She has not received hospital-provided scrubs said worries constantly about getting her children sick.

“After work I make sure I disinfect my shoes, wash hands very well, remove clothes for laundry after reaching home. I do this in order to avoid putting my kids at risk.”

Stigma from the community

Another ECP, Teddy, says she has sent her son to stay with his grandma. Between the stigmatizing from the community, and her fears for his health, she felt it was the best thing for him.

“As a result of the pandemic we’re facing long shifts, since most staff are not willing to take care of positive COVID-19 patients due to the fear and the stigma in communities. It was difficult before because I didn’t know how to go about it too, I was scared of going back to meet my family and sometimes I would get home exhausted, worried, and emotionally drained due to the long hours. I would come home late in the night just to avoid anybody home seeing me because my neighbors had started isolating me and my family. Until I decided to send my son to my mom’s place because I was certain that he will be safe and happy. Currently, I have to keep self-isolated so that my family stays safe. I miss my son — he used to welcome me home with hugs, and realized I can’t stop him from hugging me.”

Despite these challenges, Teddy maintains an incredibly positive and fighting attitude.

“I’m glad I have the courage to treat positive patients because at first everyone was scared but I stood brave to join the team. I’m glad our patients are doing better and we will be discharging our first patient soon.”

Economic fears

While Elizabeth also worries most about the health of her family, she worries about her families’ finances as well. Supplies are much more difficult to come by.

“Its’ not easy managing family and work during this pandemic, first of all it’s expensive, and we sometimes run out of sanitizer and other supplies.”

But she concluded her remarks, as any mother would:

“But still we have to fight the battle, and together we shall win.”

Please Consider a Gift Today to GEC’s COVID-19 Emergency Action Fund

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LAUNCHING THE CONTINUING EDUCATION & LEADERSHIP PROGRAM

Emergency Medicine is a vast field, encompassing a knowledge base of essentially every other discipline in medicine and a wide array of procedural skills; practitioners need to constantly stay up to date. This can be a daunting task and one that requires significant support to be achievable.

To support our graduates after they finish their two-year Emergency Care Practitioner training, we are launching the Continuing Education & Leadership (exCEL) Program. The exCEL Program will provide graduates with continuing medical education opportunities to review higher level content, learn new skills, and receive additional mentorship after they graduate. Furthermore, it will enable ECPs to attend regional retreats and larger scale conferences, take emergency care training courses, and access online resources. Once back at their home hospitals, we’re working to set up visits to work with administration on integrating emergency care into their facilities and regular phone calls to support ECPs in their new environment.The need for continuing medical education

In the US, continuing medical education (CME) is required in every field of medicine in order to provide the highest possible level of patient care. Innovations impact how patients should be assessed, treated, and cared for. As a result, medical professionals have to continue their education and stay on top of these changes. Only by doing so can they confidently provide patients with the level of care they deserve. And while continuing medical education is ubiquitous in the US, no such infrastructure exists for emergency care practitioners in Uganda.

As GEC enters our 11th year training Emergency Care Providers, we’re concentrating on CME to achieve sustainability and maintain the excellent outcomes for patients cared for by the ECPs. We’re defining CME in the broadest terms possible—striving not to just maintain skills, but to continually build new skills as the practice of emergency medicine in Africa evolves. This will take creativity on our part, as the continuing education infrastructure for emergency medicine in Africa is in its most nascent stages.

Supporting our ECPs beyond the program

Since 2010, we’ve been funding ECPs to attend regional conferences. These conferences, while a high cost for us as an organization, are invaluable to trainees. ECPs use conferences to present GEC’s work and make connections with providers in other countries and benefit from the high-level continuing education offered at each conference.

Furthermore, ECPs serve as ambassadors of the ECP model, and the concept of non-physician emergency care providers is now recognized as a critical and successful component of emergency medicine development in Africa.

 

  “AFCEM inspired me to return home and continue moving emergency care forward in Uganda. It was very impactful to have our work, as ECPs in Uganda, acknowledged by important speakers from other African countries and to hear that, because of our success, similar programs are being started in other countries.”
—Kizza Hilary, GEC’s Nyakibale Program Coordinator & ECP
 

While these conferences are valuable, they’re relatively infrequent. Thus, we deploy emergency medicine volunteers to provide CME opportunities for ECPs to review higher level content, teach new skills, and provide additional mentorship. This has been a highly successful part of our approach, but is insufficient as a stand alone method of continuing education, especially since the ECPs face challenges in their practice that are unimaginable to most doctors practicing in high income countries.

​East African conferences on emergency medicine are being organized, large international organizations, such as the World Health Organization are offering training courses in aspects of emergency care, and more online resources are becoming available for ECPs.

All of this continuing medical education comes with a cost

Our extensive volunteer network continually enhances the education we offer our trainees, we want to emphasize how critical it is for us to be able to offer them additional resources to further their education and training.

The educational experiences we are providing the ECPs as they graduate and enter practice are building on the solid foundation we build over their two years of training.

Please support ECPs to walk the path of lifelong learning and provide truly amazing care to those vulnerable patients they care for every day by donating to GEC. Together, we can continue to make lifesaving emergency medical care available to all Ugandans.​

 

 

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ULTRASOUND CHRONICLES: GLOBAL POCUS IN UGANDA WITH GEC

“I realized that by spending a few extra minutes evaluating this patient with bedside ultrasound, Alfunsi may have saved this man’s arm.”

By Dr. Leigha Winters, GEC Volunteer

Reposted with permission from SONOSTUFF: Education and entertainment for the ultrasound enthusiast

​Having traveled and worked in under-resourced settings before, I thought I had some idea of the type of clinical situations I would be encountering while teaching in Masaka, Uganda with Global Emergency Care (GEC). However, during my three weeks at the Masaka Regional Referral Hospital, I was continually amazed by the breadth and acuity of conditions seen by the medical officers (MO’s) and Emergency Care Practitioners (ECPs) in the Accident & Emergency (A&E) department. They managed some of the sickest patients I have ever seen with foley catheters for chest tubes, only four oxygen wall regulators, one intermittently functioning defibrillator, and minimal IV medications. It was exciting to watch the ECPs utilize clinical and ultrasound knowledge acquired through their diploma program to direct and improve patient care.

Take, for example, the 20-year-old man who presented with proximal right forearm swelling. He had been stabbed in his forearm, just below the elbow, at the beginning of January (over two months ago). He had presented to the hospital immediately after the injury, and had the wound closed with stitches at that time. Sometime in the next two months, he started to notice right forearm swelling and pain. He had no fevers, and there was no obvious infection around the original wound. The swelling bothered him enough in late March for him to present for medical attention. The first medical officer to evaluate him was concerned that he had an abscess under his skin, so sent the patient to the A&E for them to cut open his forearm.

When first evaluated by one of the senior ECP graduates named Alfunsi, he recognized that something wasn’t right about this story. Alfunsi elected to put his ultrasound skills to use.

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Upon placing the ultrasound probe on the patient’s forearm, he immediately realized this was not an abscess; the fluid collection didn’t look right. When color flow was placed on the large, round fluid collection, the fluid was pulsing! This was, in fact, either a pseudoaneurysm or aneurysm of the radial artery with a fistula between the cephalic vein and radial artery. In essence, the knife wound in January had poked a hole in the artery in the patient’s upper forearm and connected the artery to the nearby vein. Every time the artery pulsed, it had been pushing blood into the vein and the surrounding soft tissue. These ultrasound findings were reinforced by the fact that the patient had only a very faint pulse at his wrist near his right thumb (the distal radial artery), but a very strong pulse in his left wrist. If Alfunsi had cut open this wound, it would have bled all over the room, and the patient could even have lost his arm. Instead of antibiotics or cutting open the swelling with a scalpel, this patient needed a vascular surgeon to repair the artery and vein.

Alfunsi and the other ECPs took the initiative to call over the intern physician to explain the case. After reviewing the ultrasound findings with the ECPs, the intern agreed with them; this patient needed to be referred to a vascular surgeon. Since there are no vascular surgeons in Masaka (the hospital, in fact, does not even have a CT scanner, let alone sub-specialists), the patient was referred to a surgeon in Kampala. I realized that by spending a few extra minutes evaluating this patient with bedside ultrasound, Alfunsi may have saved this man’s arm.

This was one of many cases I witnessed in the Masaka A&E where ECP clinical knowledge and ultrasound skill greatly improved patient care and outcomes. It is incredibly powerful and fulfilling to watch expertise you have shared with ECP learners be directly translated into clinical care. In my experience, this information-exchange is the most impactful in incredibly under-resourced locations like Masaka, Uganda. Even small changes in knowledge base or imaging availability (i.e. having a bedside ultrasound available in the A&E for ECPs to use) has a huge impact on patient care, community health and system-wide practice. I am so grateful to the staff at the Masaka Regional Referral Hospital for sharing their enthusiasm and ingenuity with me during my time in Masaka, and so excited about the work that GEC is doing to help empower the medical community in Uganda.

Ultrasound Machine Fundraiser for GEC – 100% Match
Thanks to a very generous gift from the Ellis family in honor of their parents, Dan and Barbara Ellis, we will be offering a 100% match on all ultrasound donations up to $10,000. Our goal is to raise $30,000 to fix one of our current ultrasound machines and to purchase two new ultrasound machines. Can you help save lives with a contribution towards these new ultrasound machines?

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ULTRASOUND CHRONICLES: ALTERED MENTAL STATUS

“Here in our ultrasound images, we had been able to identify the root cause of his problem with no other test.”

by Dr. Lori Stoltz, GEC Ultrasound Director

Going through all of the cases of patients that I saw with the ECPs at Masaka during my last trip, one case stood out for having so many beautiful ultrasound images. The ECPs were called to help with a foley placement on the wards. The intern physician had tried and had been unable to place the foley and so had asked the ECPs to try. Deus was the ECP trainer in charge that day and he brought along the ultrasound machine. 

In front of us was an elderly gentleman, looking very ill, lying in bed, confused, moaning, on oxygen. The ECPs first took a look at his bladder with ultrasound and found an enormously dilated bladder. Next they looked at his kidneys…they were dilated with fluid on both sides. Whatever was obstructing his bladder, was obstructing the flow of urine all the way up to the kidneys. It became immediately apparent that this was the likely cause of his confusion. When urine cannot pass, the toxins and byproducts that urine is meant to expel build up. One of these, urea, causes confusion. Here in our ultrasound images, we had been able to identify the root cause of his problem with no other test. Deus noted that he was oxygen, so he looked at the patients lungs with ultrasound. The lungs were full of edema, or fluid. So, now we knew, that the kidney failure was enough to cause an overloading of fluid in his entire body causing even his lungs to be overcome with fluid.

They set about to the task of placing a foley. The catheter was expertly placed in urethra by one of the ECPs in training under the guidance and direction of Deus. A quick ultrasound exam showed the foley to be right where it should be in the bladder. Now the urine could drain from the bladder, then the kidneys and hopefully, the patient’s kidneys could continue to rid his body of the additional toxins and fluids that had built up. All around fantastic use of ultrasound. 

Ultrasound Machine Fundraiser for GEC – 100% Match
Thanks to a very generous gift from the Ellis family in honor of their parents, Dan and Barbara Ellis, we will be offering a 100% match on all ultrasound donations up to $10,000. Our goal in the next month is to raise $30,000 to fix one of our current ultrasound machines and to purchase two new ultrasound machines. Can you help save lives with a contribution towards these new ultrasound machines?

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ULTRASOUND CHRONICLES: CHILD WITH POSITIVE FAST

By: Dr. Lori Stoltz, GEC Ultrasound Director

​The eFAST exam is the most widely adopted ultrasound examination for use in the emergency department. This exam looks at six locations on the body and can identify blood in the abdomen, blood around the heart, and a collapsed lung. It take two minutes to perform. In the United States it is routinely done immediately after the initial evaluation of a patient who has had trauma, such as a car accident or other injury.

The ECPs have learned this exam and with very little else available to them for imaging internal organs in trauma patients. It is one of their favorite scans to do. One reason why…it makes their job simple and it helps them do the right thing for each patient.

Take for example a young boy who was in the emergency department the last time I visited. He was 8 years old and had fallen from a motorcycle (boda). He was tachycardic, slightly hypotensive, and he had severe abdominal pain and a peritoneal abdomen. The ECPs did a FAST exam and found free-fluid in his abdomen. The ECPs consulted the physician, who was initially hesitant, but after seeing the ultrasound images, felt it was appropriate to take the boy to the operating room. In the OR, his spleen was removed and he was discharged from the hospital in a just a few days. Ultrasound for the win!

Ultrasound Machine Fundraiser for GEC – 100% Match
Thanks to a very generous gift from the Ellis family in honor of their parents, Dan and Barbara Ellis, we will be offering a 100% match on all ultrasound donations up to $10,000. Our goal in the next month is to raise $30,000 to fix one of our current ultrasound machines and to purchase two new ultrasound machines. Can you help save lives with a contribution towards these new ultrasound machines?

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ULTRASOUND CHRONICLES: MASS CASUALTY CASE

“Within one day, I’d seen the training and careful preparation in the morning and practical application of the same knowledge in the afternoon.  A great day of Global Emergency Care at work.”

By: Dr. Michael Schick, GEC Ultrasound Director

As a second year Emergency Care Practitioner (ECP), Friday mornings are spent learning through simulation. On my recent trip to Uganda one of the morning simulations was a mass casualty event. In the simulation, a pregnant mother with her two children were riding on a boda when it crashed. Four patients, two with life threatening emergencies and two who were injured but less severely. The ECP running the case is tasked with rapidly assessing each patient, triaging them, quickly deciding who needs immediate intervention and assigning tasks to other ECPs. Each ECP is assigned to one of the patients with priorities set.

It was a fun and engaging morning of learning and I was impressed with the skills demonstrated and questions generated by the ECPs. We discussed prior mass casualty events that have come through the ED at Masaka and how the ECPs divided tasks during those events. With road traffic accidents being so common and so deadly in Uganda, this is something the ECPs had witnessed many times. Entire buses that have rolled over, two bodas with several passengers each colliding, open trucks with several people in the back that veered off the road. Each event is challenging, intellectually and emotionally, and the ECPs shared what they had learned from these events.

That afternoon, we joined the other ECP trainers in the emergency department seeing patients. The ED was busy that afternoon and the ECPs were busing seeing several patients; one with a piece of wood stuck in the bottom of the foot, another with a large laceration of the hand, a patient with pneumonia, another with abdominal pain, another with malaria. A truck pulled up outside and Alfunsi went to assess the situation. When came back in, he announced that we had a mass casualty. The truck was loaded up with several injured men, all from the same accident, some walking, some unable to walk. A truck had rolled over on the road outside of town. We were about to do what they’d just trained for.

The ECPs began putting on personal protective equipment (gloves and gowns) and taking stretchers outside and making space in the crowded department. Alfunsi assumed the role of leader, directing the others who were doing primary and secondary surveys of each patient. One of the ECPs went bed by bed with the ultrasound machine doing EFAST exams.

Having working in U.S. EDs and witnessed similar large scale trauma events over many years, I must say, the ease and rapidity with which the ECPs assessed and managed these patients was SMOOTH. What can seem like chaos for someone watching for the first time, is in fact well-orchestrated prioritization through systematic evaluation and when done right, it is a beautiful thing. When done poorly, patients can die. A true emergency provider looks past screaming and blood and fearful patients to see the problems that need an immediate intervention: abnormal vital signs, a positive FAST, or pneumothorax. This is the difference between good training and poor preparation. The ECPs were completely unfazed. Alfunsi had prioritized two of the patients as critical within five minutes. The ECPs managed each injury from large to small. One was sent to the OR and another needed transfer for a spinal fracture. The remaining patients were lower acuity and though some would be admitted, there were no further critical procedures needed.

Within one day, I’d seen the training and careful preparation in the morning and practical application of the same knowledge in the afternoon. A great day of Global Emergency Care at work.


Ultrasound Machine Fundraiser for GEC – 100% Match
Thanks to a very generous gift from the Ellis family in honor of their parents, Dan and Barbara Ellis, we will be offering a 100% match on all ultrasound donations up to $10,000. Our goal in the next month is to raise $30,000 to fix one of our current ultrasound machines and to purchase two new ultrasound machines. 

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ULTRASOUND CHRONICLES: UMBILICAL HERNIA

“As our primary diagnostic tool, ultrasound can provide a fabulous amount of confirmatory and ancillary information.”

By: Dr. Michael Schick, Director of Ultrasound

While working in the emergency department at Nyakibale Hospital in Rukingiri, Uganda a two-year-old boy arrives with his mother for persistent vomiting. He appears ill, has an elevated heart rate, but no obvious fever. Gastrointestinal illnesses are extremely common in this region of the world and account for a large proportion of childhood deaths, related to dehydration.

While most children presenting with vomiting, will also have diarrhea from either invasive of non-invasive intestinal infections this child was not suffering from diarrhea. Vomiting in isolation in a young child can indicate a benign illness like common childhood viruses, food toxicity, but can often indicate life threatening intra-abdominal emergencies or intra-cranial emergencies such as meningitis.

The child was listless, tired and not fighting against our Emergency Care Practitioners (as many toddlers normally do); he was dehydrated, but other than that the patient had no signs of meningitis. As we undressed the child, our astute Emergency Care Practitioner found the patient’s abdomen to be distended, tympanic, and with an obvious umbilical hernia. If you have never seen an umbilical hernia, it is a large protrusion from the belly button.

​One risk of any hernia is that bowel or intestine can get stuck inside it and twist, which cuts off blood flow to the intestine. Like all things, without blood flow the intestine will die. Bowel will become obstructed, necrotic, and release stool contents inside the abdomen. Life threatening infection ensues and in this region, certainly death.

As our primary diagnostic tool, ultrasound can provide a fabulous amount of confirmatory and ancillary information. We first image the four quadrants of the abdomen, which in the upper abdomen demonstrates large, dilated loops of bowel with anterograde and retrograde peristalsis. This indicated the patient has a bowel obstruction.

In the lower abdomen, his bowel appears normal, which indicates the obstruction is higher than the bowel imaged. When we place the probe on the umbilicus we see intestine within it and adjacent free fluid. We have difficulty acquiring reliable color flow from the intestine.

We consult surgery immediately and the patient is taken to the operating theater. The surgeon successfully released the strangulated umbilical hernia. Even though we had feared intestinal necrosis and perforation, the surgeon found the bowel to be well perfused. The patient had an uneventful post-surgical course.

Ultrasound Machine Fundraiser for GEC
Thanks to a very generous gift from the Ellis family in honor of their parents, Dan and Barbara Ellis, we will be offering a 100% match on all ultrasound donations up to $10,000. Our goal in the next month is to raise $30,000 to fix one of our current ultrasound machines and to purchase two new ultrasound machines.

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ULTRASOUND CHRONICLES: THE HEART. CAUGHT IN A BIND.

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By: Dr. Michael Schick, GEC Ultrasound Director

At Masaka Hospital in Uganda our Emergency Care Practitioners (ECPs) have acquired specialized emergency training in point-of-care ultrasound. In this specific diagnostic skill set, they are the most trained practitioners in the region. While teaching our ECPs ultrasound we often take to the medical wards, where pathology is plentiful. There we also interact with the ward medical/surgical teams, and often our “practice” scans drastically change management.

When we arrived on the medical ward we immediately find a young man tripodding on his hospital bed. If you have never seen a person tripod, it is alarming. It means they have their arms in front of them, supporting their body as they sit, struggling to breathe. In a healthcare setting that has no intensive care units or advanced airway interventions, this is a frightening presentation.

​The medical doctor tells us he is being treated for heart failure and pulls out a single view AP chest x-ray. Indeed, his cardiac silhouette, or the size of his apparent heart is large which is one of the signs we look for to indicate heart failure. But, I don’t see much fluid in his lungs, which is what you would expect in a typically heart failure exacerbation. Also, this is a young man, why does he have heart failure? It is usually a disease of the elderly. We considered a congenital heart defect as the cause, but still, it was a bit perplexing.

​I discuss with our ECPs that fluid around the heart or a pericardial effusion will also give you an enlarged cardiac silhouette on chest x-ray and, in this setting, cardiac tamponade from an infectious disease, such as tuberculosis or pericarditis, is a critical distinction. It is critical because the treatments are completely different. Cardiac tamponade requires drainage of the fluid around the heart with a needle and treatment of the underlying condition whereas heart failure is often treated with medications that reduce stress on the heart and remove fluid from the body. Cardiac tamponade and pericardial effusions are diagnosed primarily with ultrasound.

When we place the probe on the patient’s chest it is immediately clear he has a large, complex appearing pericardial fluid collection. He is indeed in cardiac tamponade, where the fluid around the heart is crushing the heart itself until it cannot function. He did not have heart failure and the treatment he was receiving had made him worse. He is near the brink of death. One of our ECPs assists with the ultrasound while one of the surgery medical officers drained the patient’s fluid at the bedside. The fluid removed was thick and concerning for a infection in the fluid.

In the United States, he would likely have gone to the operation room with a cardiothoracic surgeon and had his pericardium completely removed. Those resources are not available in Masaka. Though we were able to make the correct diagnosis and drain the fluid, the following day the patient died. He had likely died from sepsis associated with the infected fluid. If ultrasound becomes more widely available and training is more widely available, I believe young men like this patient can be saved. ​​

Ultrasound Machine Fundraiser for GEC
Thanks to a very generous gift from the Ellis family in honor of their parents, Dan and Barbara Ellis, we will be offering a 100% match on all ultrasound donations up to $10,000. Our goal in the next month is to raise $30,000 to fix one of our current ultrasound machines and to purchase two new ultrasound machines.

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