examine the benefits of training clinicians on the basic ultrasound skills and most .... the Ultrasound technicians, however as plastic surgeons are not available to put ...... Department of Emergency Medicine at the University of Florida Health ...
Facoltà di Medicina e Chirurgia Centro Universitario per la Cooperazione Internazionale
MASTER OF “SALUTE INTERNAZIONALE E MEDICINA PER LA COOPERAZIONE CON PAESI IN VIA DI SVILUPPO . INTERNATIONAL HEALTH AND MEDICINE FOR COOPERATION WITH DEVELOPING COUNTRIES”
POINT -OF -CARE ULTRASOUND AS AN AID TO TRIAGE, DIAGNOSIS AND INTERVENTIONS IN DEVELOPING COUNTRIES
Supervisor: Prof. Antonella Vezzani Student: Dr. Asma Ali Swaleh, MD
Academic Year 2009/2010
TABLE OF CONTENTS: Institutional Affiliation ………………………………………………………………………Pag.3 List of Abbreviations…………………………………………………………………………pag. 4 Chapter 1-Preview……………………………………………………………………………pag.5 Chapter 2-Abstract of the Project…………………………………………………………….pag.6 Chapter 3-Table of Project summary…………………………………………………………pag.7 Chapter4-Kenya………………………………………………………………………………pag.8 Chapter5-Introduction/Background……………………………………………………...….pag.12 Chapter 6-Applicability Scope………………………………………………………………pag.19 Chapter 7-Justification ……………………………………………………………………...pag.29 Chapter 8-Null Hypothesis…………………………………………………………………..pag.30 Chapter 9-Generl Objectives………………………………………………………………...pag.31 Chapter 10-Design and Methodology……………………………………………………….pag.33 Chapter 11-Data Management………………………………………………………………pag.39 Chapter 12-Time frame/Duration……………………………………………………………pag.40 Chapter 13-Ethical Consideration…………………………………………………………...pag.41 Chapter 14-Expected Application of Results………………………………………………..pag.42 Chapter 15-Project Log frame Work…………….………………………………...…………pag.43
Chapter 16-Conclusion……………………………………………………………………....pag.44 Chapter 17- Budget………………………………………………………………………….pag.47 Chapter 18-Appendages……………………………………………………………………...pag.48 References…………………………………………………………………………………………….pag.49
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Institutional Affiliation: 1. University of Parma and Parma Hospital –Department of Anesthesia and Critical Medicine 2. Ministry of Medical services –Kenya 3. Geneva Foundation Medical Education and Research - GFMER
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LIST OF ABBREVIATIONS: 1. WHO –World Health Organization 2. US – Ultrasound 3. MoH- Ministry of Health 4. ED-Emergency Department 5. MO-Medical Officer 6. CO-Clinical Officer 7. CT –Computed Tomography 8. MRI-Magnetic Resonance Imaging. 9. PI-Principle Investigator 10. BLS-Basic Life Support 11. ALS/ACLS-Advance Life Support/Advanced Cardiovascular Life Support 12. ATLS-Advanced Trauma life Support 13. PHTLS/PTC –Pre Hospital Life Support/Pre Hospital Trauma Care 14. PALS-Pediatric Advanced Life Support 15. ABCDE-Airway, Breathing, Circulation,Disability and Exposure. 16. FAST- Focused Assessment with Sonography in Trauma 17. AAA-abdominal aortic aneurysm 18. NICU-Neonatal Intensive Care Unit 19. HIV-Human Immunodeficiency Virus 20. RTA-Road Traffic Accidents
DEDICATION
This Project is dedicated the most important Person in my life: My Father
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CHAPTER 1: PREVIEW For doctors dealing with emergency and critical patients, bedside ultrasound would help them save time, save lives, and give them direct, real-time knowledge of the patient’s condition. The short version: It makes a physician’s job faster and easier. Portability in ultrasound is one of those technologies that make a person wonder “Why this isn’t used everywhere?” Emergency ultrasound has demonstrated itself to be a powerful tool for rapidly and accurately diagnosing trauma, including four very common, life threatening emergencies where delay can cause serious harm or death: abdominal aortic aneurysm, traumatic hemoperitoneum, pericardial tamponade, and ectopic pregnancy .Point of Care ultrasound has been so successful at improving patient outcome and emergency workflow. Although some believe there are very limited indications for the use of ultrasound in the emergency setting, I believe in expanding and maximizing the use of this tool in developing countries…… . ‘’ As a powerful device in the emergency toolbox, it has shown its ability to save lives, speed up the delivery of medical attention, improve overall treatment, and help doctors make triage decisions.’’ Eric Justian, Freelance Writer in Muskegon, MI.
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CHAPTER 2: ABSTRACT: Introduction/Background: Recent advances of Ultrasound in affordability, durability, portability and applicability in multiple medical disciples have brought ultrasound to the forefront as a sustainable and high impact technology for use in developing world clinical settings as well. However, ultrasound's impact on patient management plans, program sustainability, and its feasibility of its applications in this setting has not been well studied. Objectives: The goal of the study is to understand how feasible, applicable and sustainable is point care ultrasound and its scope in different medical specialties especially in emergency and critical care situations in low resource setting. The study shall also examine the benefits of training clinicians on the basic ultrasound skills and most important to be able to use it in making diagnosis and clinical decisions in management plans.Methods: This will be a prospective longitudinal study; it will take place in a district hospital in the coastal part of Kenya- Port Reitz Hospital. Recruitment will be in all departments. All ultrasound exams will be bedside. Data sheets for each ultrasound scan will be collected and analyzed to determine patient demographics, which ultrasound applications were most frequently used, and whether the use of the ultrasound changed patient management plans. Patients will be given questionnaire to assess their views on the service provided. Expected Results: We expect that Point-of–care ultrasound will improve patients’ management and procedures outcome with final outcome of reduction of mortality and morbidity rates. We anticipate the improvement of general health services and increase patients’ satisfaction. Conclusion: Point–of–care Ultrasound is believed to be a feasible and sustainable imaging modality in a low-resource setting.
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CHAPTER 3: PROJECT SUMMARY TABLE
Project’s title
Point -of -Care Ultrasound as an Aid to
Triage,
Interventions
Diagnosis in
and
Developing
Countries.
Location
Port Reitz District Hospital
Project Duration
24 Months
Target Group
All Patients who will be attended at the Emergency Room, wards and Maternity and need an ultrasound exam either for triage, diagnosis or an interventions.
Direct Beneficiaries
Patients attended at the Port Reitz District Hospital
Indirect Beneficiaries
Ministry of Health
Partners
Ministry of Medical Services Kenya and Parma Hospital
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CHAPTER 4:KENYA: GEOGRAPHY AND HEALTH SYSTEM
Statistics: Total population: 36,553,000 Gross national income per capita (PPP international $): 1,470 Life expectancy at birth m/f (years): 52/55 Healthy life expectancy at birth m/f (years, 2003): 44/45 Probability of dying under five (per 1 000 live births): 121 Probability of dying between 15 and 60 years m/f (per 1 000 population): 432/404 Total expenditure on health per capita (Intl $, 2006): 105 Total expenditure on health as % of GDP (2006): 4.6
Figures are for 2006 unless indicated. Source: World Health Statistics 2008
KENYAN GEOGRAPHY Kenya is the world's forty-seventh largest country (after Madagascar). It is comparable in size to France, and is somewhat smaller than the US state of Texas. From the coast on the Indian Ocean the Low plains rise to central highlands. The highlands are bisected by Great Rift Valley; fertile plateau in west.
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The Kenyan Highlands comprise one of the most successful agricultural production regions in Africa. The highlands are the site of the highest point in Kenya (and the second highest in Africa): Mount Kenya, which reaches 5,199 meters (17,057 ft) and is also the site of glaciers. Climate varies from tropical along the coast to arid in interior. The Republic of Kenya is a country in Eastern Africa. It is bordered by Ethiopia to the north, Somalia to the northeast, Tanzania to the south, Uganda to the west, and Sudan to the northwest, with the Indian Ocean running along the southeast border. The geography of Kenya is diverse. Kenya has coastline with Indian Ocean (536 km long), large plains and numerous hills. Central and Western Kenya is typified by the Great Rift Valley. Three highest mountains of Africa are located in Kenya or its vicinity. Those are Mount Kenya, Mount Elgon and Kilimanjaro. The Kakamega Forest in western Kenya is relic of an East African rainforest. Much larger is Mau Forest, the largest forest complex in East Africa. Kenya is home to people of many different ethnic origins. About two-thirds speak Bantu languages, and are mostly from three ethnic groups – Kikuyu, Luhya, and Kamba. Other peoples include the Kalenjin, Luo, Maasai, Turkana, and, on the coast, the Mijikenda. Most people in the north-east of Kenya are Cushitic speakers; they make up less than three per cent of the population, but live in one third of the country. Kenyan Asians and Arabs make up only a small proportion of the population, but they have a lot of commercial power. Seventy per cent of the population is Christian, 19 per cent are animist, and six per cent are Muslim. Most people live by farming or, in drier areas, by herding livestock. Other people work in Kenya’s industries, some of which are the most developed in East Africa: milling maize and wheat flour, spinning and weaving cotton, making household goods, refining cane sugar, and brewing beer. In towns, increasing numbers of Kenyans work in small businesses (as metal-workers or market traders, for instance). This is known as jua kali, or the "hot sun", under which they work.
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OVERVIEW OF THE HEALTH SYSTEM IN KENYA The ministry of health in Kenya has its headquarters at Afya house in Nairobi. Its divided into two ministers: * The minister for medical services * Minister for public health Kenya is a low-income country situated in Sub-Saharan Africa. There are 8 provinces and 71 districts in the country and together with the MoH headquarter they form the basis of the health care system. The major health care provider is the MoH, which operates more than half of all health facilities in the country. The public delivery system is organized in a traditional pyramidal structure. First level care is provided at dispensaries and medical clinics. The next level is the health centres and sub-district hospitals. Third level care is provided at district hospitals and provincial general hospitals. There are two national hospitals; Moi Referral and Teaching Hospital in Eldoret and Kenyatta National Hospital, located in Nairobi Resources for health are scarce and the disease burden is high in the country, just as in other countries in the region. The estimated total per capita expenditure on health was USD 19.2 in 2001/02, which is about half of what is required to finance the minimum health package set by the World Health Organization . The shortage of resources for health applies also to real resources. There are about 5,000 doctors in Kenya, for a population of 32 million, i.e. about 6,400 inhabitants per doctor. The major source of funding is the households (51%), followed by the government (30%) and donors (16%). With regards to deaths and disease burden, Kenya like most sub-Saharan countries’ main health concerns are HIV/AIDS, tuberculosis, malnutrition, diarrheal diseases, malaria and poor maternal health. According to the Nairobi Urban Health Demographic Surveillance System (NUHDSS), AIDs and Tuberculosis combined are responsible for 50% mortality in persons aged 5years and above. The health situation however, is not only threatened by infectious diseases. Road incidents pose a major health threat as Kenya has one of the highest traffic casualties per 100,000 vehicles in the world
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(Odero W., et al, 2003). According to the FIA Foundation for the Automobile and Society, after HIV/AIDs, road traffic accidents (RTA’s) are the leading cause of premature death and disease burden for men aged 15 – 45 years. Ethnic and political violence are also continuing to increase as significant threats to the nation’s health situation. Interpersonal violence injuries (homicide) are the second most common contributor to the burden in the population aged five years and above, followed by road traffic accidents. Among the homicide deaths, gunshot wounds, and blunt trauma as a result of mob justice, are the most common modes of injury (NUHDSS 2003 -2005).
While emergencies and casualties are one of the major cause of mortality and morbidities in Kenya, its health system still lacks proper emergency support. Most of the hospital has poor emergency services for basic life support, diagnosis, triage and secondary management. This problem is manly encountered in district and peripheral health centers where supplies, staff and basic health care services are lacking.
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CHAPTER 5: INTRODUCTION/BACKGROUND
More than half of the world’s population does not have access to at least some form of radiologic examination. In industrialized countries, ultrasonography has become a classic tool. Meanwhile, developing countries are lagging increasingly far behind. Ultrasonography has been recommended for developing countries by the World Health Organization (WHO) since it is a technique that provides images immediately, is relatively inexpensive, can be carried out on an out-patient basis, and has no side effects{ World Health Org Tech Rep Ser 723.} In much of sub-Saharan Africa, diagnostic
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imaging in patient care is limited to some urban settings and lack of adequate health care facilities, personnel and diagnostic tools remain a major barrier to health-care delivery. With non-governmental organizations efforts to strengthen and scale-up existing public sector health care models in rural and low resource settings, attention has focused on appropriate placement of cost-effective, durable technology that will assist local health care providers in the clinical care of their patients.
Ultrasound is a safe and proven diagnostic imaging modality that has been in use for many years all over the world, but its importance and applicability of this aged technology has yet to be appreciated and put in use routine use in the developing world. At the moment Ultrasound might not be seen as an essential tool in the health care system of many developing countries, its indirect impacts when put in proper use will however result into remarkable change in the outcome of health services, patients satisfaction ,mortality and morbidity rates and the cost of health services and cost sharing. When these objectives are achieved, it directly has its positive implication on the whole health system of the country, its health professionals and people seeking health care services. Ultrasound has long been recognized as a powerful tool for use in the diagnosis and evaluation of many clinical entities. Over the past decade, as higher quality, less expensive scanners were developed, US has proliferated throughout various specialties. US is no longer limited to radiology but is being utilized by at least 8 different specialties. One specialty which has contributed new research regarding ultrasound's multiple clinical applications is Emergency Medicine.
Ultrasound diagnosis has been regarded as the gold standard for most pregnancy-related problems (placental site, foetal lie, foetal heart, gestational age within accepted measurement error, normal nonpregnant uterine cavity), differentiation of cystic and solid masses, urinary or biliary obstruction, and detecting increased fluid content in the peritoneal, pleural or pericardial cavity or ventricular brain space. In some cases the ultrasound findings in correlation with the clinical presentation led to a highly probable ultrasound diagnosis (ectopic pregnancy, appendicular mass, tuberculous peritonitis, hepatic masses). The ultrasound investigation improved the clinical diagnosis in 30% of clinical cases. Ultrasound is a useful adjunct to clinical diagnosis in a wide variety of pathologies found at the district
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health care levels, but particularly so for pregnancy-related, gynaecological and hepato-biliary problems. Prerequisites for rational use of ultrasound are well-defined indications, management guidelines for common findings and training of the clinicians in the interpretation of the ultrasound examinations.(Hermann Bussmann et al ,2001).Ultrasound gives near perfect test performance when making such diagnoses (N'Gbesso et al.1996; Ong et al. 1996; Fang et al. 1999; Dinkel et al. 2000; Sivyer 2000)
The attraction of immediate bedside sonographic examinations in the evaluation of specific emergent complaints makes it an ideal tool for the emergency specialist. The ability to perform these focused studies will allow for a more expedient and safer disposition of patients. The social and economic pressures to triage, diagnose and rapidly treat patients have fueled ultrasound's use as a primary screening tool in the Emergency Department (ED). Most institutions now utilizing emergency screening ultrasounds report faster turn around times and more expedient diagnosis of potential lifethreatening emergencies such as internal hemorrhage following blunt trauma, abdominal emergencies, ectopic pregnancy, pericardial tamponade, and aortic aneurysms. One recent study found that with the use of emergency physician-performed pelvic ultrasound length of stay was decreased in the emergency department by a median of 120 minutes.( Shih CHY et al 1997)
History has always seen and followed the rule that Ultrasound technique and its use is only for acknowledged expertise of the board-certified and actively practicing sonographers/Radiologists and the Ultrasound technicians, however as plastic surgeons are not available to put every stitch, nor a cardiologist to auscultate every pericardium ,neither can radiologist be available to perform every ultrasound exam especially in emergency and essential care medical situations where urgent and a basic exam with the ultrasound machine when done would change the whole picture of the management and treatment/intervention outcome of the patient. Thus, it should be believed and put in action that basic ultrasound skills should be part of the armamentarium of emergency and critical care medicine especially in the developing world, where accidents, war, violence and natural disasters are some of the main causes of mortalities and morbidities. For this to be achieved, it is mandatory and
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has be suggested(Kirkpartric W et al 2007) that every clinician especially those working
in
developing countries has the need to be trained and be able to master the skills in the basic ultrasound ,at least for emergency and essential care interventions and diagnosis.
As ultrasound is increasingly attracting interest in the field of emergency and essential care medicine, it has to earn its place with respect to CT scan and MRI, which provide easy –to-read images and will remain indispensible for some indications. Ideally one cannot compare the accuracy of these heavyweights of modern imaging with ultrasound, but in the situation of a low recourse setup where one only depends on the Clinician experience, physical examinations and at times outclass radiography, a judicious Ultrasound scan will reinforce the physical examination, this is of great importance in situation where previously one had to rely on clinical experience and basic tools such as stethoscope, perhaps supplemented by an ill defined radiography that would even then fail to change the clinical judgment of the clinician.
Ultrasound today is being used in a variety of clinical situations. While reserved for traditional imaging providers just two decades ago, today it allows clinicians to save lives on a daily basis. Much more than looking for intra-abdominal fluid in a trauma patient, ultrasound is a tool that can help clinicians at every step. Visualization of the heart in real time allows a previously “blinded” clinician to assess cardiac function with incredible precision in a wide variety of acutely ill patients. Procedures that once carried risks for significant complications can now be performed with near total safety when guided dynamically under ultrasound. Resuscitation of critically ill patients is now driven by direct ultrasound observations and measurements instead of inferences from physical examination and invasive measures. Lung ultrasound, a concept scoffed at just a few years ago by traditional imaging providers is now finding broad acceptance and holds promise for high accuracy and safety in a multitude of venues. It is clear that bedside ultrasound has tremendous capabilities and potential for improving patient care. It is also quite clear that point of care ultrasound should be at far more bedsides than it currently is. Whether it is in the developed world or developing nations many patients
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who could benefit from point of care ultrasound do not. The developing world, however, has the added challenge of unaffordable equipment that is difficult to obtain.(Blaivas M et al 2009)
To the well known advantages of ultrasound, low cost, bedside use, portable, repeatability without risk, and its increasing spectrum of indications from optical to lungs to soft tissues, all which are one of the indications of application of this device as a tool to improve the health care services in low recourse setups. Clearly the results yielded by an ultrasound depends on the skill of the operator, however let us return to the time when, for instance auscultation was not part of clinical routine(Lichtenstein D et al 2000).The Point of Care ultrasound implies to a screening ultrasound, as the name implies, not a complete formal study. It is rather a highly focused, limited, goal directed exam with the expressed purpose of answering a select set of questions. Simply put, these are a list of primary examinations that may be critically time dependent and/or may show significant immediate benefit to the patient. These questions include: Is there a pericardial effusion present? Are there gallstones present? Is there hydronephrosis evident? Is there free peritoneal fluid? Is there a welldefined intrauterine pregnancy? Is there an abdominal aortic aneurysm (AAA) present? Is there a foreign body?
Point- of- Care ultrasound in simple words means the application of the ultrasound use where the patient is. This implies to the use of ultrasound on bed side as a bed side examination, during ward rounds, in emergency setups as in Casualty departments within hospitals, in Intensive care units. It also implies to the use of Ultrasound exam outside the hospital setup in cases of disasters, wars, remote areas, outreach health services and in Ambulance while the patient is being transported. This can now being achieved thanks to the evolution of this aged technique into a new imaging paradigm, and the availability of the portable ultrasound machine. Apart from the place of use, Point of care ultrasound also implies to the use of the technique to a point of exam, focused and target to a specific medical question. This is possible as ultrasound, as described earlier can be applied in 8 deferent fields of medicine and can be used to examine almost every part of the body as required. Moreover, interventions including life saving procedures line Insertion of a chest tube, central line, ascitic tapping
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and sometime peripheral line placement especially in children can be done without risk using ultrasound guidance.
‘Point-of-care ultrasound’, available in any kind of critical setting, was viewed as a technical impossibility until a decade ago. However, through the work of multiple dedicated researchers and authors around the world, it is now one of the fastest spreading imaging applications in a variety of clinical specialties including critical care, surgery, emergency medicine, anesthesiology, general internal medicine, pediatrics and others. The novel concept of point-of-care ‘Ultrasound Resuscitation’ has recently evolved with the availability of high quality portable ultrasound devices, in combination with an increasing number of clinicians who have developed point-of-care ultrasound skills to help manage patients in ‘critical’ situations. Clinical scenarios turn into ‘critical’ ones when there is a performance gap between the patient needs and the resources available for decision making and problem solving (Crisis Resource Management). This typically occurs in the acutely ill patient (Emergency US/Intensive/ Critical Care US), and/or where human or technical resources are limited (Screening US/Triage US/Remote US/Primary US).Point-of-care image acquisition and interpretation, integrated with life support protocols (BLS, ALS/ACLS, ATLS, PHTLS/PTC, PALS, etc.), which follow the ‘ABCDE’ or ‘Head-to-Toes’ evaluation methodology allow for rapid and effective decision making, enhance triage, diagnosis, therapy, monitoring, and patient follow up.(WINFOCUS)
Outside the hospital setup, in situations of mass casualties, natural disasters and in other extreme situations, ultrasonography can be applied as basic triaging tools to aid classify patients’ further management and referral. A mass-casualty incident is one in which the number of patients with injuries exceeds the available medical resources to care for them in a timely manner. In such a situation, the numerous advantages of ultrasonography make it an ideal triage tool for helping clinicians rapidly screen patients. Experiences during the 1988 Armenian earthquake and the 1999 Turkish earthquake demonstrated the proficiency of ultrasound in providing rapid clinical data to the physicians caring for the mass-casualty patients.( O. John Ma,et al 2007)
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The use of ultrasonography as a triage tool in these mass-casualty situations has numerous advantages. Ultrasound may be applied to a broad category of trauma patients. In many studies, the focused assessment with sonography in trauma (FAST) examination has been demonstrated to be highly accurate, sensitive, and specific (Kimura A et al 1991, Rothlin MA et al 1993, Rozycki GS et al 1993,). New handheld units make this technology portable; ultrasound examinations can now be performed in makeshift triage areas and in the prehospital setting. It generally takes 4 mins or less to perform an ultrasound trauma-screening examination (Ma OJ, Mateer et al 1995), which also facilitates performing serial examinations on patients to monitor their status. Ultrasound is noninvasive. No contrast materials need to be administered to the patient, and there is no radiation exposure involved. Moreover, ultrasound is safe for patients who are pregnant, have a coagulopathy, or have had previous abdominal surgery. These features of ultrasonography make it especially appealing to emergency physicians and critical care specialists, who will encounter many challenges in a mass casualty incident. Every emergency department and hospital will be overwhelmed with patients affected by the event. Admission rates will be high, which will challenge the hospital infrastructure’s capacity. Diagnostic capabilities within the hospital’s radiology department will be hard-pressed to meet the challenge of these high patient volumes. A large percentage of the trauma patients will have multiple blunt or crush Injuries, including some patients who may be pregnant. Patients may present with cardiovascular disease exacerbated by the mass-casualty incident [O. John Ma,et al 2007]
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CHAPTER 6: THE APPLICABILITY AND SCOPE OF POINT OF CARE ULTRASOUND Most content taken from Emergency Ultrasound Textbook, 2nd edition unless indicated (O.John Ma, James R. Mateer, Michael Blaivas: Emergency Ultrasound,2ND Edition) 1.Obstetric and Gynecological Emergency: Ultrasound imaging, a front-line diagnostic tool for perinatal care, is rarely available in the developing world, where maternal and newborn mortality rates are starkly higher than elsewhere. The development of portable and inexpensive medical ultrasound machines offers the possibility of broader use of this technology.
1a: First-Trimester Pregnancy Ultrasonography is the primary imaging modality used in pregnancy. In first trimester pregnant patients who present with vaginal bleeding or abdominal pain, ultrasound can be used to distinguish ectopic pregnancy from threatened abortion or embryonic demise and congenital abnormalities. The primary goal of emergency sonography of the pelvis in the first trimester is to identify an intrauterine pregnancy, which essentially excludes the diagnosis of ectopic pregnancy. Secondary objectives are to detect extrauterine signs of an ectopic pregnancy, estimate the viability of an intrauterine pregnancy, and characterize other causes of pelvic pain and vaginal bleeding. In addition, sonographic detection of free fluid outside of the pelvis can help emergency physicians expedite the care of a patient with a ruptured ectopic pregnancy. Emergency bedside sonography is not intended to define the entire spectrum of pelvic pathology in early pregnancy. A follow-up comprehensive pelvic ultrasound examination is indicated after the initial focused bedside examination, the timing of which is dictated by the clinical scenario. 1b:Second and Third Trimester Pregnancy:
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Over the last 30 years, ultrasound has played an essential role in the care of the obstetric patient. The body of knowledge and expertise in obstetric sonography is now enormous. Ultrasound is the primary imaging modality for evaluation of uterine, cervical, and amniotic fluid abnormalities; placental and umbilical cord problems; and determination of gestational age, fetal congenital abnormalities, multiple gestation, and fetal presentation. While some of these applications are of limited relevance in the emergency setting, certain information can be rapidly obtained with bedside ultrasound that is potentially critical to the emergency care of an obstetric patient. During this time period, the major indications for its use are the initial assessment of the pregnant trauma patient, evaluation of vaginal bleeding and preterm labor, and evaluation of abdominal pain. Emphasis will be placed on a focused or goal-directed ultrasound examination to rapidly measure fetal cardiac activity, estimate gestational age, and exclude placenta previa. Additional applications include assessment of amniotic fluid volume, cervical length and fetal position, and the evaluation of nonobstetrical causes of abdominal pain. 1c: Gynecolocical considerations: Female patients with lower abdominal pain presenting to the emergency department or acute care clinic may represent a diagnostic challenge. Faced with a large differential diagnosis , their clinical work-up is often time and resource consuming. Bedside ultrasound is the diagnostic imaging modality of choice for the majority of cases. It provides real-time information that expedites patient care and disposition.
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Differential Diagnosis of Lower Abdominal Pain in Female Patients
GASTROINTESTINAL Appendicitis Inflammatory bowel disease Irritable bowel syndrome Constipation Gastroenteritis Diverticulitis URINARY TRACT Cystitis Pyelonephritis Nephrolithiasis REPRODUCTIVE Ectopic pregnancy Intrauterine pregnancy Pelvic inflammatory disease Tubo-ovarian abscess Ovarian cyst Hemorrhagic functional cysts Ovarian torsion
Dysmenorrhea Endometriosis
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2: TRAUMA AND EMERGENCY 2a: FAST {Focused Assessment with Sonography for Trauma} Ultrasound (US) was first used in the evaluation of trauma patients in Europe in the 1970s. [Vicki E. Noble et al 2007]. The objective of the FAST exam is to detect free intraperitoneal and pericardial fluid in the setting of trauma. It is a highly sensitive test for answering this binary question. The scan involves 4 views: the right upper quadrant (hepatorenal angle / Morrison’s Pouch); the left upper quadrant (spleno renal angle); the pelvic view; and the subxiphoid/pericardial view. Trauma is one of the commonest cause of death in the developing counties due to accidents and falls. Most patients tend to die due to lack of proper management of this condition primary due to misdiagnosis and/or delayed diagnosis. In this era of cost consciousness especially in already low resourced settings, evidence shows that using FAST as a screening tool helps decrease testing, hospital stays, and intensive care unit requirements and thus can also significantly decrease cost.
The current practice of referring patients with acute trauma to ultrasound room is time wasting and causes delay in diagnosis and management increasing the chances of mortality and morbidity. Rather than rolling emergency patients to a sonographer, then rolling them back to the emergency room, then waiting for the results to be processed and interpreted by other people, the physician can perform ultrasound on patients directly and immediately. The physician can find the source of the trauma right from the emergency facility. As the physician peers into the patient’s body with the ultrasound, he or she can make a rapid diagnosis and immediate decision about the best course of treatment. A simple FAST makes proper diagnosis possible. Without such examinations, it can be more difficult for clinicians to determine appropriate treatment. For example reports from some countries indicate that a significant portion of all abdominal surgical interventions ("explorative laparotomy") may have been avoided if simple diagnostic imaging services such as ultrasound had been available.
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3. CRITICAL CARE ULTRASOUND: Ultrasound imaging has a huge variety of applications for patients on intensive care units. These include both diagnostic and therapeutic applications; some of the more common applications are listed below. Ultrasound is readily portable and can often be performed at short notice. The size of machines and the quality and resolution of images has improved over the last decade. It is a versatile imaging modality with many applications on intensive care units. 3a}Detection of Pleural Fluid Bedside ultrasound can be used to differentiate pleural effusions from consolidation, which may not be apparent on a plain chest radiograph.Echography is extremely accurate with 100% sensitivity and a specificity that is more than 90% accurate in the definition of pleural effusions. It can also be useful for marking a safe entry point for aspiration. Ultrasound is also useful in the detection of Pneumothorax where the absence of a gliding sign and comet tail appearance indicates lack of contact between the visual and parietal pleura. M Mode ultrasonography also shows a typical pattern which varies in patients with Pneumothorax, this is known as the ‘seashore appearance.’ 3b}Focused Cardiac Scanning Bedside cardiac ultrasound evaluation in the ED is limited to a global assessment of contractility and the detection of pericardial effusions/tamponade. This is applied to patients who are in an arrest or shocked condition. The utility of this scan is to highlight the need for intervention such as perciardiocentisis, and also to help with decisions such as the appropriateness of ongoing resuscitation attempts. 3c}Vascular : Detection of Deep Venous Thrombosis DVT is a common complication in Critically Ill patients in Intensive care units and wards. Many patients go on developing DVT without being noticed earlier. Point of care ultrasound performed on patients who a bed ridden and critically ill can give the physician an idea of whether there is need of therapeutic interventions and treatment of these patients.
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4. ULTRASOUND AS A GUIDE OF EMERGENCY INTERVENSIONS AND PROCEDURES: Invasive procedures are frequently performed in the emergency department. Traditionally, these invasive procedures have been performed by emergency physicians who relied on physical assessment for making the correct diagnosis and surface landmarks for determining the correct approach for an invasive procedure. In recent years, the use of bedside ultrasound has been incorporated into the practice of many emergency physicians to guide or assist in the performance of a variety of invasive procedures. The use of ultrasound guidance (dynamic guidance) or ultrasound assistance (static guidance) to perform certain procedures can decrease complications when utilized correctly. The decision to perform a procedure under ultrasound guidance or ultrasound assistance is based on the procedure itself. Some procedures are simply inherently more dangerous when not performed under real-time guidance. In the case of others, there is only slightly more danger when real-time visualization is not utilized after an initial ultrasound assessment. For these procedures, it is often a matter physician experience and preference that may be the deciding factor. Procedures such as paracentesis, thoracentesis, and abscess drainage are frequently performed using ultrasound assistance since the fluid collections tend to be static, and once anatomy and pathology are marked out, it is typically safe to proceed blindly. Vascular access, paracentesis, and foreign body removal are examples of applications typically performed under ultrasound guidance.
4a:Central line placement: Establishing reliable vascular access in an emergency situation is of critical importance. Many factors, including body habitus, volume depletion, shock, history of intravenous drug abuse, congenital deformity, and cardiac arrest can make obtaining vascular access in the critically ill or injured patient extremely difficult. The introduction of real-time bedside ultrasound into emergency and acute care settings has been an important advance for facilitating rapid and successful vascular access. Blind insertion of an IJV or SV catheter failed in 10% to 19% of patients and complication occurred in 5% to 11% of patients, depending on the operator’s experience. Major complications are
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Pneumothorax, catheter tip misplacement and vascular complications, such as artery puncture, hematoma or neural injury, the major which occurs during the puncture of the vessel and catheter advancement. Study done at the Parma Hospital reports that detection of complication after insertion of central line was easier and more effectively done using point of care ultrasound.(Vezzani A et al 2010)
4b: Paracentesis Confirming the presence and location of peritoneal fluid prior to paracentesis is simply an extension of the typical Focused Assessment with Sonography for Trauma (FAST) examination. Indications for performing abdominal paracentesis in the emergency department include the evaluation of the patient with new onset ascites, obtaining fluid for diagnostic purposes in the patient with suspected cancerous or spontaneous bacterial peritonitis, and as a therapeutic intervention to relieve discomfort or respiratory embarrassment in symptomatic patients with massive ascites. Occasionally, paracentesis may also play a role in clarifying the nature of the intra-abdominal fluid found in a patient with a positive FAST examination but no clear history of trauma. Routine bedside ultrasonography prior to every paracentesis that is performed in the emergency department is highly recommended. One reported series of 100 emergency department patients undergoing abdominal paracentesis demonstrated a significantly higher procedural success rate for ultrasound-assisted paracentesis compared to the traditional non image-guided technique (95% vs 65%). 4c: Regional Anesthesia: Regional Anesthesia is becoming a common form of anesthesia especially in emergency situations where patients conditions are not favorable for General anaesthesia.Also common to be used in Limb surgery especially after trauma and accident. In the past few years an emerging body of anesthesia literature has demonstrated the significant role ultrasound can play in enhancing both the performance and success rates of these various regional block techniques. The development of more portable ultrasound equipment, higher resolution transducers, and improved picture-processing technology
25
(such as compound imaging) have all helped accelerate this process, and the utilization of ultrasound for performance of regional anesthetic blocks is moving toward becoming standard of care. For all of the commonly performed nerve and plexus blocks, ultrasound imaging allows for real-time visualization of the target nerve in most patients. This, in turn, allows the operator to deposit the anesthetic agent in a precise location, simultaneously enhancing all the desirable operating characteristics of the procedure and minimizing complications.
5. POINT OF CARE ULTRASOUND AS A TRIAGING TOOL: Triaging is one of the important stage in an emergency set up. How does a doctor know which patient needs an emergency surgery or intervention? Sometimes clinical signs and symptoms do not guide to a proper decision .With the current practice where a patient has to wait for a radiologist technician to perform an ultrasound which will give the doctor an idea of the exact diagnosis and way forward for the management is time wasting and puts the patient at risk of complications especially if diagnosis and specific intervention will be delayed. The increasing mobility and portability of sonography has led to its increasing use at the patient' disposal has increased its use as a triaging tool not only in hospital emergency rooms but also in mass casualty, in disasters and in wars. In circumstances in which conventional radiography is unavailable, such as at trauma scenes, mass casualty situations, or at the bedside with unstable patients, sonography can provide unique and essential information about these patients. . It provides potential immediate diagnosis and has the flexibility for evaluating a multitude of injuries normally requiring diagnosis in such emergency situation for the purpose of triaging and soughing out the patients needs. The use of ultrasonography as a triage tool in these mass-casualty situations has numerous advantages. Ultrasound may be applied to a broad category of trauma patients. In many studies, the focused assessment with sonography in trauma (FAST) examination has been demonstrated to be highly accurate, sensitive, and specific. New handheld units make this technology portable; ultrasound examinations can now be performed in makeshift triage areas and in the prehospital setting. It generally takes 4 mins or less to perform an ultrasound trauma-screening examination, which also
26
facilitates performing serial examinations on patients to monitor their status. Ultrasound is noninvasive. No contrast materials need to be administered to the patient, and there is no radiation exposure involved. Moreover, ultrasound is safe for patients who are pregnant, have a coagulopathy, or have had previous abdominal surgery.( Ma, O John et al )
6:POINT OF CARE ULTRASOUND IN NEONATAL ICU AND PEADIATRIC EMERGENCY: In Pediatrics Ultrasound is an especially appealing imaging modality in children. Examinations can be performed at the bedside, at times with the child being held by a parent. This diagnostic test is noninvasive, involves no contrast or ionizing radiation, and is considered virtually risk-free. Also, pediatric patients generally have less body fat and thinner abdominal walls, which enhances the ultrasound examination. Trauma remains the most common cause of morbidity and mortality in children. Traumatic injuries result in a great potion of hospital admission each year. In the pediatric age group, blunt trauma is more prevalent than penetrating injuries. Twenty to 30% of pediatric trauma cases involve the abdomen. Timely, accurate, and cost-effective evaluation of children suffering from blunt abdominal trauma remains a challenge for physicians. The history and physical examination form the foundation of patient evaluation; however, they may be difficult or impossible to obtain in children who have altered mental status, central nervous system trauma, or distracting injuries. In one study of children with blunt abdominal trauma, an initial physical examination was considered reliable in only 41% of cases.( Bondestam S et al 1992 )The physical examination has been reported to be misleading in up to 45% of injured children. Although the physical examination is an important piece in the diagnostic puzzle, the clinician must resort to other modalities to adequately evaluate and treat the pediatric blunt abdominal trauma patient.Timily diagnosis using Ultrasound in pediatric trauma is important in determining the need for hospitalization, duration of bed rest, resumption of activity, and need for follow-up. In Neonatology, point-of-care ultrasound includes the use of ultrasound by clinicians for functional echocardiography, cranial ultrasound and other uses such as assessment and obtaining of an
27
intravenous line. Of all the uses in NICU, a transcranial ultrasound is one of the most simple and important investigation that can be done on a neonate who has signs or predisposing factors for brain abnormalities. With the increasing rate of Encephalopathies due to many preventable and non preventable causes, it is important to perform a transcranial ultrasound to atleast all preterm, neonates who have convulsed and all neonates with features of neurological deficit. This simple exam will help in coming up with diagnosis and help in following up children who develop neurological disorders.
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CHAPTER 7: JUSTIFICATION OF THE STUDY The goal of this study is to examine the feasibility, applicability and sustainability of point of care ultrasound in low resource setting. To understand how this technique could be used as an aid to diagnosis, triaging and performing interventions in this patient group with final expected outcome of improving patients’ management outcomes. Point of Care ultrasound is seeing growing institutional acceptance simply because it’s practical. It’s fast, it saves lives, and it gives attending clinicians the immediate feedback they need to deliver the best treatment. In addition, this study aims to assess the importance of training and making ultrasound use a basic skill necessary for every doctor and clinician in developing country, especially those working in emergency and critical medicine departments.
The focus of this study is to measure the outcome of patients’ management, satisfaction and long time benefits in reduction of mortality rates when point of care ultrasound is applied in health care systems. There are many useful applications of ultrasound which have not been studies in this setting, however, the most common of all applications is the obstetrical ultrasound which is mainly used only for emergency conditions like placenta previa and abruptio. Essential application of this technique in Antenatal care like in examination of head position and placental abnormalities are not routinely done, but we have examined the benefits of these exams in the going observational study, HIV, Malaria and Neurobehavioral Development in Early Childhood (PI = P. Holding; NON-SSC#102).
With the increase of ultrasound application in many medical fields, there is need to study its benefits in especially in the emergency and critical care in this setting. This study will advance our understand to the benefits of this simple technique in saving and improving patient care in developing countries. Furthermore, the results will help in formulating protocols for the application of point of care ultrasound as routine technique which must be used for basic management of patients, diagnosis and interventions.
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CHAPTER 8: STATE THE NULL HYPOTHESIS
1. Patients management outcomes will improve when point of care ultrasound is used in the diagnosis Triage and in performing intervention procedures with the final outcome of reduction of mortality and Morbidity rates. 2. Patients satisfaction, hospital stay and outpatient waiting time will be reduced when point of care ultrasound is used where necessary, with the final outcome of improved Healthcare provision. 3. The use of point of care ultrasound will reduce the cost and improve the overall healthcare resources utilization. 4. Doctors who have basic ultrasound will have better diagnostic and management skill than who do not have those skills.
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CHAPTER 9: GENERAL OBJECTIVES
1. General objective of the study is to understand how feasible, applicable and sustainable of point care ultrasound is and its scope in different medical specialties especially in emergency and critical care situations in low resource setting. 2.The study of Its applicability in these different medical specialties as an aid to the triage, diagnosis, interventions, overall patients management with the overall target of reducing mortality and morbidity rates . 3. To examine the benefits of training clinicians on the basic ultrasound skills and most important to be able to use it in making diagnosis and clinical decisions in management plans. Specific objectives: 1. To measure the outcome of use of point of care ultrasound by: A} Patients Variables: •
Waiting period in casualty
•
Duration of hospital stay
•
Overall Cost of Medical services
•
Patients satisfaction
B} Quality of Medical services: •
How long does it take for a doctor to come up with a diagnosis?
•
Quality of management plans
•
Complications of procedures and interventions
•
Overall hospital Resource utilization
•
Referral rates
31
•
Mortality and Morbidity rates 2. To improve the skills and clinical performance of doctors attending to this population group:
•
Does it change doctor’s clinical decision on type of care and management?
•
Does it save the doctors time and help to fasten diagnosis?
•
Does it make performance of procedures easier for the doctor?
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CHAPTER 10: DESIGN AND METHODOLOGY
Study Site Study will take place at Port Reitz District hospital. Owned by the Ministry of Medical services, Kenya.It is located in Port Reitz area in Mombasa District. The hospital operates specializes as a mental institute, a children's hospital and prosthetics centre. It is a 166 bed hospital offering other services including Antenatal and Emergency medical care. The nearest Referral hospital is the Coast Provisional Hospital. This hospital is currently one of the busiest district hospitals at the Kenyan Coast and a centre for all primary care of accidents and emergencies from the nearby airport and deport before transferring to the Provisional Hospital. This hospital also serves a greater portion of the population around the Coastal mainland and island as well. The hospital is a well established district hospital with one consultant Surgeon, a busy Antenatal clinic and maternity department, casualty and outpatient services, paediatric and adult wards. . Ultrasound in this hospital is currently only used when requested by the attending physician during ward rounds and always done by the Radiologist technician. With the current set up and the use of ultrasound occasionally, patients are always moved to the ultrasound room and booking prior the examination is mandatory. Currently, there is no physician trained for basic ultrasound use, and its use in interventions and triaging has not been applied or studied. Recruitment of participants will take place in the casualty department, wards and maternity at the Port Reitz District hospital. All patients who will need an ultrasound exam for diagnosis, intervention or for triage will be recruited regardless to their home residency.
Study Population As the study is multidisplinary, participants will include any patient requiring an ultrasound exam for a clinical reason. The study population will therefore be comprised of all age groups and sexes
33
Inclusion Criteria 1. All Patients seen at the casualty department who require ultrasound exam for diagnosis, Intervensional procedure or for triage. 2. All patients in the wards who will require ultrasound exam for any clinical reason or procedure
Exclusion criteria 1. Exclusion will depend on the situation at the time of examination and might be related to refusal to have the exam or procedure against medical advice.
Rational for Animal Use (not applicable) No animals will be used in this study.
Sampling Sample size determination We propose to enroll as many patients as possible depending on the patients turn out numbers, ultrasound requirements, emergency needs and procedures to be done.
Sampling procedure Patients of all ages and sex will be recruited for the study and undergo an ultrasound exam depending on the condition of disease , procedures and any other need which the attending physician will find necessary to be done. There will be a protocol to guide the attending physician on how to arrive to who needs an exam and for what purpose.
34
Procedures This is a prospective longitudinal infant study that will follow patients while in the hospital admitted or seen as outpatient, casualty and Maternity department. As there is no data indicating the use of ultrasound as a point of care tool in this setup, there will be a need to perform a needs assessment by reviewing hospital and clinic logbooks for atleast the past 3-5 years to determine which clinical condition would likely address the diagnostic concerns of clinicians working with this patient population. Specifically, patient demographics, admission diagnosis, discharge diagnosis, prenatal clinic log information ,maternity ward logbooks ,referral book with reasons for referral and mortality reports will be reviewed before the actual study begins. Recruitment will be at the sites specified, patients will be done an ultrasound exam when need for diagnosis, procedure or triage is identified by the attending physician. All exams will be recorded in study specific clinical forms and hospital log book. Clinical evaluation and results collection form Basic demographic information of the patient will be recorded in normal hospital admission forms or patients note books. Attending physician will be required to clerk the patient according to clinical guidelines followed in the hospital and ministry of health. The study will have specific information forms which will be filled by the attending physician .Each patient will be identified by a Unique identification number {UNID}.Age, sex, type of exam and reasons for doing the ultrasound exam will be recorded.
Ultrasound examination procedure and Training program. Attending physician will be required to use the portable ultrasound machine and examination should take place where the patient is located. Patients will not be moved to specific area for the exam. There will no need of prior booking for the patient to have the ultrasound exam done. Booking will be done for those who will need a follow up exam or repeated procedure. When procedures requiring sterility
35
and privacy are to be done, patients will be moved to procedure rooms or theater depending on the clinical condition and type of procedure required. Basic ultrasound technique will be taught to the medical officer, clinical officers and maternity nurses. We propose that training will take place within the hospital and will be carried out by tutors from Parma Hospital University and also will involve the Provisional Radiologist consultant. The training will take place after the needs assessment is done using hospital records. The goal of the training will be “goal-oriented” approach of emergency and critical ultrasound. Duration of training will be 5 weeks. WEEK 1: -This week will be for the basic introduction to the Ultrasound machine, technical parts, type of probes, maintenance and other basic technical issues regarding the type of machine will be used. -Basic anatomy of the body, important landmarks and clinical assessment of patients requiring an ultrasound exam will be done. WEEK 2: – Focused assessment with sonography in trauma (FAST) – Ultrasound evaluation of the abdominal aorta – Hepatobiliary ultrasound – Renal ultrasound WEEK 3: – Ultrasound evaluation of pregnancy during the first trimester – Ultrasound evaluation of pregnancy during the second and third trimester – Pregnancy dating ,fetal position and placental abnormalities WEEK 4: 36
– Ultrasound-guided procedures – Soft tissue and vascular ultrasound – Regional anesthesia. WEEK 5: – Basic echocardiography – Transcranial ultrasound – Lung ultrasound
Introduction of portable ultrasound into the health services of the Lugufu refugee camp, Kigoma District, Tanzania .Hand-on bedside training. Transfer of technology
37
No Ultrasound images will be transferred outside the country. The provisional Radiologist will be expected to review difficult cases which the attending physician will have doubt in clinical decision making. Description of Type of Data to be Collected Data will be collected on clinical ultrasound examination form. It will be filled by the attending doctor performing the exam. There will not no clinical data of the examination recording, but simply whether the exam was useful in helping to come to a diagnosis or in doing a procedure. All patients who underwent an ultrasound exam will be given a questionnaire at the time of discharge where their general opinion on the service provided will be collected. Patients’ opinions will be guided by questions provided in the questionnaire. For children, their parents or guardian will answer the final questionnaire. Provisions for Data Verification and Validation All data will be double entered into a database and checked for internal consistency. There will be no internal or external positive or negative controls used as to validation of each examination.
38
CHAPTER 11: DATA MANAGEMENT
Data Storage and management Data collected on all study participants will be assigned a UNID by the study. The database linking personal identifiers to this study number will be kept by the Principal Investigators and the Database Manager. Original data collection in clinical forms and questionnaire will be stored in a locked filing cabinet at designated study offices in Port Reitz Hospital. No other information which contains personal identifiers will be circulated. This database will be stored on back-up files after analysis in case there will be a need to review the records of the project. All data will be entered into computers using appropriate statistical package.
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CHAPTER 12: TIME FRAME/DURATION OF PROJECT
After receiving required ethical reviews from both Italian and Kenyan ethical review boards, subjects will start to be enrolled. The study is anticipated to begin enrollment in May 2011 pending receipt of appropriate ethical requirements and funds. The study is will continue for 1 year. There after the use of the ultrasound as point of care technique could be adopted as a routine clinical protocol on site and the sustainability will be directed to the already trained stuff , the Ministry Of Health and the individual Hospital .
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CHAPTER 13: ETHICAL CONSIDERATIONS
Human Subjects As the main aim of the study is to provide clinical and medical benefits to patients, it is acknowledged that involvement in the study will result in the more prompt diagnosis, less complication of procedures and satisfaction of patients towards the medical service provided. Long term benefits are reduction of mortality, morbidity and improvement of general health services for the population. It is hoped that in the future the use of point of care ultrasound will be a routine procedure incorporated as a national guideline for patient management. Informed Consent Patients will be explained the procedure by the attending physician. Informed consent will be obtained where situation is not an emergency. In emergency cases, the attending doctor will have to make clinical decision for the best interest of the patient. A copy of the consent form in the appropriate language will be provided to the patient, parent or guardian of the infant being recruited. A signed copy of the consent form will be retained for the study files, which will be maintained onsite. If a signature cannot be made, a thumb print from the consenting patient/ parent will be used. The attending physician will have witness the signatures/thumbprints. Risks This is a minimal risk study. Ultrasound is the safest clinical diagnostic tool known. Risks depend on the clinical presentation of the patient and procedure been carried out. There are no direct risks associated with the machine or probes. With experience of the attending physicians, risks of performing procedure guided by an ultrasound are minimal. There is no major risk when Ultrasound is used only during diagnosis without performing invasive procedure. Patient might complain of minimal pain during the ultrasound procedure depending of the clinical conditions. All risks are dependent on the patients’ factors and operator’s skills.
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CHAPTER 14: EXPECTED APPLICATION OF RESULTS
The study expects to show that the use of point of care ultrasound will improve the diagnostic, interventional and triaging services in low resource setup with the target of improving health services for the population and to achieve into reducing mortality, morbidity and health care resource utilization. We believe that the study will give Positive results to show that use of ultrasound is feasible and sustainable in low recourse setup and that it is a simple tool that can change the lives of both the doctor and the patient. Future plans are to make the use of this tool as a routine and a protocol in all health institutions around the country. This could be extended in the future to include ultrasound outreach programs and services for the population.
It is hoped that the study will also bring out the importance of emphasizing on ultrasound training in undergraduate Medical courses in Kenyan Universities and in clinical medicine course offered in Kenya. Furthermore, we hope the Ministry of Foreign Affairs Italy/CUCI and the University of Parma could support Training of Doctors from African in specifically Ultrasound techniques and its applicability in basic emergency and critical care medicine.
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CHAPTER 15: CONCLUSION 1.Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania David Adler & Katanga Mgalula & Daniel Price & Opal Taylor. Our feasibility study demonstrates the enthusiastic embrace of a portable ultrasound unit by the health care staff of a large refugee camp in the tropics and suggests that health care providers in austere settings can use portable ultrasound to facilitate the care of their patients. Furthermore, it demonstrates that a portable ultrasound unit can be a sustainable addition to the health care services in such a setting
2.Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008 Sachita P Shah, Henry Epino, Gene Bukhman, Irenee Umulisa, JMV Dushimiyimana, Andrew Reichman4 and Vicki E Noble Our research suggests that after an initial training period, an ultrasound program led by local health care providers can be sustainable and lead to accurate diagnoses in a rural international setting long after the instructing clinicians have departed. Further study in this area is needed to gauge the diagnostic accuracy of ultrasound when performed by local health care providers’ months to years after completion of a training program. In addition, the economic impact of ultrasound services on resource utilization, institutional referral patterns and patient care in this type of setting needs further study. Longitudinal evaluation of this training program is ongoing.
3.Ultrasonography as an aid to diagnosis and treatment in a rural african hospital: a prospective study of 1,119 cases steinmetz and berger de´partement de chirurgie, centre hospitalier, clamecy, france; fondation de jumelage, hospital le samaritain, vevey, Switzerland The aim of this study was to assess the utility of ultrasonography in a rural African hospital in Cameroon with scarce resources. Ultrasonography was judged useful when treatment was decided upon in 62% of the cases. This study demonstrated the value of ultrasonography in the context of a developing
country
and
the
conditions
by
which
its
use
could
be
delineated
43
CHAPTER 16: PROJECT LOG FRAME WORK
Project Description
Indicators
Source Verification Assumptions
General Objectives: 1.To understand how feasible, applicable and sustainable point-of- care ultrasound is in different medical specialties especially in emergency and
Reduction of
Mortality rates, referral
Results might be not as expected due to
book and discharge
faulty techniques, misuse of machine, and
summary.
bad maintenance.
Mortality and Morbidity rate.
critical care situations in low resource setting. 2. The study of Its applicability in these different medical specialties as an aid to the
Results might be not as expected due to
triage, diagnosis, interventions
faulty techniques, misuse of machine, and
and overall patients
bad maintenance.
management.
Which population group
3. To examine the benefits of
benefited the most, from
training clinicians on the basic
Data sheets?
ultrasound skills and most
Poor skills and inadequate training may led
important to be able to use it in
to poor outcomes.
making diagnosis and clinical decisions in management
Reduction of
plans.
Mortality and Morbidity rate.
44
Improvement of
Mortality rates, referral
diagnosis, triage
book and discharge
and procedure
summary
outcomes. Shortening the period of patients waiting and rates of referrals
Expected Results:
Improvement of health
Reduction of
Mortality, morbidity rates. The population d the ministry of health
services for the population,
mortality,
Discharge summary and
reduction of resources
morbidity, hospital hospital accounts.
results and apply the use of ultrasound in
utilization and better clinical
stay and recourses
routine management.
have to appreciate the benefits and positive
outcome of management plans. utilization.
ACTIVITIES: 1.Baseline Data collection
From hospital
patient demographics,
records
admission and diagnosis,
Records mights not be available
discharg prenatal clinic log information ,maternity ward logbooks ,referral book with reasons for referral and mortality reports will be reviewed 2.Training of the
1.Trainers and
Skills attained and
Improvement of general clinical
Clinicians,MO and some
Consultants both
practicing data sheets
management.
Maternity nurses.
visiting and local 2.Guidelines
45
3.Portable ultrasound machine 3.The main study will involve The Doctors, recruitment , the US exams
clinicians , data
and data collection
base entry team,
Data sheets
Lack of funds to support the whole project
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CHAPTER 17:BUDGET
Budget Summary :1 year
US$
Ksh (80)
a. Personnel, salaries and benefits disbursement
10000
1,600,000
b. Patient costs, travel, food and/or supplies
0
0
c. Major equipments
12,000
960,000
d. Supplies
4000
320,000
e. Operating expenses, postage, printing, etc
2000
160,000
28,000
2,240,000
Total average annual budget
Detailed budget/Justification of budget The item costs are given in US dollars, but at the end, the total equivalent in Kenyan Shillings at the time of writing the project is also given. Major components of the budget include: 1) Personnel (Medical officer, Clinical Officer, community liaison, Data Base Manager, Data entry clerks ) salaries and benefits disbursement $ 10,000 2) Major Equipments $12,000 (Portable ultrasound machine and computer) 3) Supplies(Ultrasound Gel, procedure needles)4000$ 4) Operating expenses, postage, printing, etc. 2000$ (Paper, printing, scanning,)
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CHAPTER 18: APPENDAGES
1.
List and state role of each investigator
2.
Curriculum Vitae of each investigator
3.
Case Record and Data Forms
4.
Informed Consent Documents
48
REFERENCES
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Subramanian, MD
8. Kimura A, Otsuka T: Emergency center ultrasonography in the evaluation of hemoperitoneum: A prospective study. J Trauma 1991; 31:20–23 9. Rothlin MA, Naf R, Amgwerd M, et al: Ultrasound in blunt abdominal and thoracic trauma. J Trauma 1993; 34:488–495 10. Rozycki GS, Ochsner MG, Jaffin JH, et al: Prospective evaluation of surgeons’ use of ultrasound in the evaluation of the trauma patient. J Trauma 1993; 34:516–527 11. Rozycki GS, Ochsner MG, Schmidt JA, et al: A prospective study of surgeon-performed ultrasound as the primary adjunct modality for injured patient assessment. J Trauma 1995; 39:492–500 12. Ma OJ, Mateer JR, Ogata M, et al: Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma 1995; 38:879–885 13. Emergency Ultrasound, 2nd edition O. John Ma, James R. Mateer, Michael Blaivas 14. Manual of Emergency and Critical Care Ultrasound-Vicki E. Noble, Bret Nelson, A. Nicholas Sutingco 2007 15. ultrasonography as an aid to diagnosis and treatment in a rural african hospital: a prospective study of 1,119 cases j.-p. steinmetz and j.-p. berger de´partement de chirurgie, centre hospitalier, clamecy, france; fondation de jumelage, hoˆpital le samaritain, vevey, Switzerland
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16. Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania David Adler & Katanga Mgalula & Daniel Price & Opal Taylor 17. Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008 Sachita P Shah*1, Henry Epino2, Gene Bukhman3, Irenee Umulisa4, JMV Dushimiyimana4, Andrew Reichman4 and Vicki E Noble2 18. Feasibility of an ultrasound service on district health care level in Botswana Hermann Bussmann1, Emy Koen2, Dyna Arhin-Tenkorang3, Grace Munyadzwe4 and Jochen Troeger5 19.Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax:An alternative to chest xray Antonella Vezzani, Claudia Brsasco, Salvatore Palermo,Claudio Launo,Mario Mergoni & Francesco Corradi 20. Introduction To Emergency Ultrasound A Review Of Justifications, Indications And Significant Findings Steven A. Godwin M.D. Steven A. Godwin, M.D. is Assistant Residency Director, Department of Emergency Medicine at the University of Florida Health Science Center Jacksonville. 21.Bondestam S: The needle tip echo. J Ultrasound Med 11(6): 253 n 256, 1992. 22 Prenatal sonographic detection of adrenal hemorrhage confirmed by postnatal surgery Shiuh-Bin Fang MD1, Hung-Chang Lee MD1, Jin-Cherng Sheu Md,. Zun-Jen Lo MD,Bor-Lin Wu MD 23. Ultrasound patterns and frequency of focal liver lesions after successful treatment of amoebic liver abscess Joerg Blessmann1, Nguyen Dinh
Khoa2, Le Van An2 and Egbert Tannich
24. Transabdominal ultrasound and its correlation with clinical findings in gynaecology. Ong S, Duffy T, Murphy J. St. Vincent's Hospital, Dublin 25. Sonography for Selecting Candidates for Laparoscopic Cholecystectomy Hans-Peter Dinkel1,2, Simon Kraus1, Johannes Heimbucher3, Roland Moll1, Joachim Knüpffer1, Heinz-Jochen Gassel3, Stefan M. Freys3, Karl-Hermann Fuchs3 and Gerhard Schindler1 26. Pelvic ultrasound in women.Sivyer P.
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