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Emergency Ultrasound

PGY4

Trish Henwood, MD, FACEP and Kristin Dwyer, MD, MPH

Since 2001, Yale and Stanford have partnered with Johnson & Johnson to provide 40 residents per year with a global health scholarship to work in Uganda, South Africa, Liberia, or Colombia. Residents borrow a portable Vscan ultrasound from the Yale Ultrasound Department to take with them.

In 2016, Jacob Schoeneck, a Johnson & Johnson global health scholar, worked at the Church of Scotland Hospital (COSH) in Tugela Ferry, South Africa for six weeks.


 Image: Jacob using the Vscan.

“The Vscan was invaluable during my time at COSH. We had limited access to plain films and no access to CT, so ultrasound frequently filled in that diagnostic vacuum. Because I had a portable ultrasound, I was asked to come look for pathology in the wards daily. Diagnoses I made included cholecystitis in the female medical ward, intussusception in pediatrics, and DVTs in the surgical ward.

Tugela Ferry is the birthplace of XDR-TB, and I had numerous opportunities to use the FASH exam. On my first day, a 32-year-old woman presented with a cough and progressive shortness of breath for two weeks. She had been sent in by a mobile clinic and had gone for a chest radiograph prior to arrival. We put the film up on the lightboard and were surprised to find a right sided tension pneumothorax with tracheal deviation. Ultrasound showed a large complex pleural effusion, and we used ultrasound to guide chest tube placement, releasing a gush of air and 2L of tuberculous fluid.

 

Image: Right-sided tuberculous tension pneumothorax on CXR.

             
Image: Complex pleural effusion on ultrasound.  Video Clip here.

COSH has two ultrasounds with curvilinear probes, one in casualty and the other in the radiology department. I tried to encourage the local physicians to use their machines for more point of care applications by doing a lot of bedside teaching. In addition, I had the opportunity to give lectures on cardiac, renal, biliary and trauma ultrasound at the weekly doctors’ meetings. The physicians were most interested in using ultrasound to identify serious pathology that would necessitate transfer to the tertiary care center without relying on CT.

One morning a 58-year-old man came in with weakness and chest pain. He stood up from the chair where he had been seated, took a few steps, and then collapsed with agonal respirations. He was lifted onto a stretcher, found to be unresponsive and pulseless, and CPR was started. On the first pulse check, the Vscan showed minimal cardiac activity with a large left ventricular clot. We didn’t have access to tPA to lyse the clot, and we weren’t able to get ROSC. I suspect this patient was having an MI, but unfortunately there wasn’t a functioning ECG during our time at COSH to diagnose it.

 

Image: Left ventricular clot.  Video Clip here.

 
I truly enjoyed my time in South Africa and having the chance to practice in a very different clinical setting. I was forced to expand on my ultrasound knowledge. If I wanted an ultrasound, there weren’t any techs or radiologists to do it for me. This experience also reaffirmed how useful and versatile ultrasound can be in remote low-resource practice environments.”

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