Posted on behalf of Abby Montague (PL3)
I am fascinated by ultrasound. In medical school I had the privilege of rotating at HCMC for an ultrasound rotation through the emergency medicine department. I spent a month learning everything from bedside FAST (Focused Assessment with Sonography for Trauma) exams and the basic bedside applications to looking for retropharyngeal (behind the throat) abscesses with intra-oral probe and confirming fracture reduction in the arm. Unfortunately, keeping these skills up during residency hasn't really been a priority due to the ready availability of excellent ultrasound technicians and pediatric radiologists. But I like looking at the images my patients get and guessing the diagnoses before the official read comes back. I occasionally would page through my Pocket Atlas of Emergency Ultrasound (by one of the HCMC faculty among others) to remember how I would do the studies myself.
Then I started preparing for Haiti.
Aside from X-rays, we knew an ultrasound machine was the only available imaging within the St. Damien's. I was excited about renewing my skills and asked Ben Trappey, our MedPeds hospitalist attending coordinating our trip, if the staff at the hospital would be interested in a little handbook on bedside use of ultrasound that I could do for my academic project.
After cramping my wrist at 5 am trying to get good RUQ views with the portable ultrasound in my call room, I had enough images for my project. I put together pictures of the buttons from our machines in the ED and on the floor for a mix of the way symbols appear and reviewed some radiology literature for images of clinical pathology. I printed up the guide on Saturday before we left and Ben presented it to our Haitian contacts when we arrived.
Ultrasound machine with Abby Montague's newly created bedside use of ultrasound booklet easily accessible on the side
One of the first ultrasounds we did here was evaluating a child with TB for pleural effusion (fluid around the lung). It was so grossly abnormal at first we couldn't find our landmarks. As we kept looking, we realized we were probably seeing TB cavitations within consolidated lung tissue (holes in the lung). It was impressive. The next was a child with abdominal distention who ended up having a complex cystic mass that was so large we couldn't tell if it was coming from the liver or the left kidney (on opposite sides of the body). Kids don't come to the hospital until they are really sick and their imaging findings, whether chest xray or ultrasound, tend to be dramatically pathologic. At first, the staff just asked us to go do the ultrasounds which couldn't happen until most people were gone for the day. Gradually, they started crowding around to look at the images in real time.
One of the new residents was the first to accept the transducer. Each ultrasound, I would pass it around to see if anyone wanted to practice, receiving a lot of smiling and head shaking with French explanations I couldn't understand. The resident, Renee, was admitting a child she suspected had intussusception (intestine stuck within intestine). After explaining my lack of training with intestinal imaging again (having attempted an appendix ultrasound the first week), I asked her to just start looking since we had equal lack of experience in this case. I shamelessly endorsed my ultrasound guide and showed her the pages about the difference between the probes and the standard probe positioning. She started scanning the abdomen and found a tubular structure with a target appearance in cross section. Never having ultrasounded a child before, she recognized the characteristic finding without prompting. The staff all came around to look and we had a long discussion about the next steps. With no fluoroscopy available, the child would need to have a reduction through an open abdominal surgery. A stunningly textbook history and suggestive abdominal film would have sent the child for reduction regardless. But I can't describe how satisfying it was to watch the resident add to her own clinical suspicion using ultrasound with minimal help.
One day I was asked to ECHO a cyanotic newborn. I am comfortable with the subxyphoid view but I couldn't remember the orientation of the alternative views of looking at the heart. The very same Pocket Atlas I used in MN had made its way to Haiti prior to our arrival and and I grabbed it from the stack of English textbooks on the registration desk to re-orient myself. Renee and I talked through the chapter on cardiac imaging, each tried a couple views and came to the conclusion the right ventricle was small and we could not determine much else. But the physician I had handed the book to was now flipping through other chapters to see what was possible with this machine they've acquired and now wanders in our direction to look over our shoulders whenever we bring the ultrasound out from radiology.
I have not stopped being completely anxious about people relying on our novicely obtained images. We are asked on a daily basis to ultrasound outside of our scope of familiarity - like the ECHO's for congenital heart disease, the intestinal ultrasonography, and examinations for biliary atresia. I've only turned down one request to look for peripheral pulmonary stenosis since I don't even know how to find the pulmonary arteries. But the giant septated pleural effusions are becoming more familiar and a new staff tried her hand at visualizing one today.
I've revived an old love and maxed out the space on my flash drive bringing home images to share with Ben. But I wish I had an image of the look on Renee's face when she found the right angle to visualize the heart. I felt like I really had brought something to give. Our Haitian colleagues have been most generous in sharing knowledge, skills, and gracious acceptance. My hope is that in this small way, we've shared something worthwhile in return.
Posted on behalf of Hope Pogemiller (MP4) as she tells the legend of the day Adam Foss (MP4) brought the incentive spirometer to St Luc
St. Luc hospital cares for patients 13 years and older. Since the doctors are trained primarily in adult medicine, the style of care delivery leans toward the adult end of the spectrum. As is often topic of discussion in the med/peds realm, delivery of care to children and adults is fundamentally different. This has remained constant in our observations at St. Luc.
In the past few weeks, we have been able to help patiently tease out history and current complaints from young patients at St. Luc. Noting a dire need for incentive spirometry, Adam introduced bubbles today to a 15 year old male with a severe respiratory infection that leaves him sweating in rigors each evening and unable to sit up in bed due to generalized weakness.
Adam Foss (MP4) making incentive spirometry
His chest xray, unstable respiratory status, and continued fevers have raised concern for tuberculosis.
He was therefore ordered to produce an early morning sputum during rounds one morning.
He cried out and mumbled something that was translated by staff as him refusing to cough.
Hospital pain scale
We contemplated a change of perspective.
We helped him sit and encouraged him to try to cough, but he finally explained that he was afraid because it was so painful in his chest to cough.
We mentioned that we could possibly obtain a gastric sample instead of a sputum sample, and the physicians agreed. They threatened him with insertion of a tube down his throat to convince him to cough.
This had not been our idea, and we were beginning to feel uneasy when Adam enthusiastically announced that this child absolutely must blow bubbles.
We left his bedside as he crumpled in a heap on his bed in relief that the team was moving on to discuss the next patient.
After rounds, the local physicians helped Adam find a piece of circular plastic (formerly used to hang IV fluids) and an old medicine bottled filled with soap.
Our incentive spirometer was born.
Despite my reservations that an adolescent, severely ill Haitian boy would muster up the courage to try the bubble-blower, our patient became suddenly enthusiastic as his face lit up with joy when he was able to blow bubbles. Despite his fatigue and chest pain, he was able to produce bubbles for 5 minutes and promised to try once each hour while awake.
The local physicians and patients in the adjoining beds shared our patient's enthusiasm, and Adam has effectively added creative incentive spirometry to the treatments available at St. Luc.
- a fellow resident or medical student thinking "Should I do my International Rotation in Tanzania?"
- or a faculty member thinking "Emily, you should be spending more time talking about your experience at the hospital"
- or my distant relative motivated by guilt, worrying about my well-being and thinking "how am I related to you, I would never associate with such impulsive travel plans and decision making."