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Emergency Ultrasound

International Ultrasound: A View from the Frontlines: Point-of-care ultrasound in Kenya with Dr. Greg Bell

By Ellen Stein MD and Trish Henwood MD

Kenya1Q: You have a key role in increasing the use of point-of-care ultrasound in Kenya. How did that happen?

A: I definitely did not have that as a goal of mine, but found it to happen by serendipity. From early in my medical training, I knew I wanted to do some volunteer work overseas but had no preference for location or nature of the work. I had gone to med school at Ohio State, completed an EM residency at the Medical College of Wisconsin, did a research fellowship at the University of Colorado and ended up in North Carolina for my first ‘real’ job after training. A friend in North Carolina had a friend of a friend in Kenya so that’s where I went.

Q: What did you do there?

A: I worked at the A&E (Accident and Emergency) departments at both a training hospital in Nairobi (Aga Khan University Hospital) and a large rural hospital near Bomet, Kenya (Tenwek Hospital). The patients at Tenwek were far sicker than in Nairobi and the providers there, as in most rural locations, essentially had only x-ray for imaging. Thanks to an innovative radiology tech at Tenwek, however, that rural hospital had an old ‘giant thing’: a 1960s ultrasound machine with a 5-inch hazy screen. This tech, Solomon, had no formal training but was a master of the old beast. This opened my eyes to the benefits even an outdated ultrasound machine can provide.

Q: Is that when you started to focus on bringing ultrasound to rural Kenya?

Kenya2A: No. That experience raised my motivation to learn ultrasound, but without any clear picture of what I wanted to do with the knowledge. I took a number of emergency ultrasound courses, which through twists and turns led me to my current position as Ultrasound Director at the University of Iowa. The idea of bringing ultrasound to Kenya was born at a conference focused on global health. As often happens at these events, we were led through a group exercise on identifying dreams we had for advancing global health. I thought of Solomon and the ancient ultrasound unit. A Google search for applying ultrasound in underdeveloped settings led me to Point-of-care Ultrasound in Resource-limited Environments (PURE). A year later, I was in Rwanda with PURE learning how to run effective training programs, train the trainers, assess effectiveness of trainings, and institute quality assurance methods. I still was not clear on what I was going to do next, but I knew I was moving in the right direction.

Q: How did you reconnect with Kenya?

A: Just as my introduction to Kenya was serendipitous, so too was my re-introduction. The epitome of “Small World” occurred at ACEP’s Scientific Assembly. I had previously heard about the great work of the Aga Khan ED Director, Dr. Ben Wachira, who was advancing the use of imaging modalities in Kenya. It was at the annual ACEP meeting in Seattle that a mutual friend made the introduction. Ben told me about his Emergency Medicine Kenya project (www.emergencymedicinekenya.org) and that is when everything came together for me.

Q: Tell us about the program you are running in Kenya.

A: We work with a foundation through which donated equipment can be acquired, and with equipment as a carrot to participants, we train providers (nurses, techs, doctors) from all over Kenya in what essentially is a flipped classroom model. They receive study manuals with embedded videos ahead of time, which they are expected to master outside the formal classroom. This ensures that the majority of face-to-face training time is focused on hands-on learning. Each participant must attend three several-day training sessions separated by periods of time during which they take a donated machine with them back to their facility and perform scans. Those who successfully complete all 3 sessions are given a machine to be used at their facility indefinitely. Although the machines are not sophisticated and only have one curvilinear probe, they are able to perform cardiac, obstetric, and abdominal exams, which previously had not been possible. To date, 80 people have started the training and 23 have completed all 3 sessions.

Kenya3Q: What are some of the obstacles you are facing?

There are too few providers in Kenya and they are not given time off for continuing medical education, especially those at government hospitals. As a result, attendance at three multi-day trainings that usually are far from their facilities is extremely difficult for them from a cost and time perspective. Additionally, without reliable internet there is no way to institute ongoing quality control measures to be sure that scans are being performed and interpreted accurately outside the training environment.

What lies ahead?

A: I would love for the training and equipment to spread to more hospitals and even beyond Kenyan borders. Ben and I intend to establish and evaluate outcome measures of the clinical benefits of ultrasound at these hospitals and to make the program into a train-the-trainer, disseminating the knowledge more widely.

If you are interested in getting involved in this effort, please visit www.emergencymedicinekenya.org or contact Greg.

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