Tag Archives: ultrasound

Checking Out Our Classrooms

Figuring out how to play podcasts on the projector in one of the classrooms we're using.

Figuring out how to play podcasts on the projector in one of the classrooms we’re using.

We got access to the school’s facilities the day before our classes started. It was great being able to tour the school and the surrounding areas in Istanbul briefly. It was a nice break from dealing with some problems with our housing situation. (Five girls sharing one not so functional bathroom doesn’t usually equate with smooth sailing) But at the end of the day, we all went out to eat a delicious dinner! All in all, a successful day.

Multi-Day Clinic in Playa Verde

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Multi-Day clinic in Playa Verde. We taught some ultrasound stuff to some of the local health care workers out here in the bush. It was good to teach, but these people really have zero background in basic anatomy learning about this kind of stuff, that made the training pretty difficult.
Still, it was good to see some patients and do what we could.

Here is a photo of us practicing with the SonoSim, which is turning out to be a great tool to teach basic ultrasound, as well as the anatomy and pathology.

We saw a ton of patients out here during the clinic and we did several prenatal ultrasounds as well as pediatric cardiac screenings. Thanks for your support!

Intro to Teaching ‘Intro to Ultrasound’

I never thought I would be happy to be stuck inside a small hotel room due to rain, but here I am…. stuck in a small hotel room…. due to rain. Time to catch up on this blog.

Armidale kept us very busy. Between teaching the procedure-oriented ultrasound to the 3rd years (see two posts below), the intro to ultrasound course to the 1st and 2nd years (see this post), and all the outings with the UNE students (see Armidale’s police blotter), we are very glad to have these next two days to ourselves to take it easy in Newcastle. Anywho- let’s dive into that Intro to ultrasound course Carter mentioned earlier;

Professor Mckeown of UNE had already given an intro to ultrasound lecture to the 1st and 2nd years weeks ago, and they have since watched a few of UCI’s ultrasound  videos on iTunes U, but this week was the students’ first hands on experience with the ultrasound devices. Thursday morning, we started off with Bryan giving a lecture to about 90 students about the benefits of ultrasound in the emergency setting; full of Dr. Fox’s classic ultrasound examples, and the ever so famous Thoracotomy video. Bryan did a great job keeping their attention with his classic wit and humor (the bloody video helped too), and by the end, the students seemed very eager to hit machines.

We had the students divide up into 4 groups, each one getting a two hour hands on session (one group Thursday after the lecture, and the other 3 the following day). During these sessions, we showed the students basic cardiac ultrasound, having them get the parasternal long, apical 4-chamber, and sub-xiphoid views. Next we had them find kidneys, liver, spleen, IVC, abdominal aorta, bladder and prostate; explaining a few clinical applications along the way. The sessions ended with a 5 minute practical exam for each student; testing them on knobology, finding and identifying the organs, and overall approach to ultrasound (a complete summary and write-up of this event is in the works).

Judging from the students’ surprising (and natural) skill and overall enthusiasm, we think this little experiment of an ultrasound course was a huge success. We had a lot of positive comments from the students and faculty at UNE, and we are excited to start planning next year’s course (that is until a few lucky members of UCI class of 2016 take over).

We can only hope that we have this much success as we start our ultrasound/iPad initiative here in Newcastle. But that is two days from now, until then I have a date with sweat pants, a rigid hotel bed, and a sci-fi novel.

-Lance

Linear probes and cow parts

Our first few days at UNE have been great.  The School of Rural Medicine has shown us amazing hospitality and the medical students here are enthusiastic and friendly

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The first part of our week here has involved helping add ultrasound education to a pre-intern year boot camp that UNE is putting on for their third year medical students.  We attend lecture with them in the morning, and help with ultrasound clinical correlates in the afternoons.

Yesterday’s session was on the diagnosis and management of pleural effusions, pneumothorax and other pulmonary diseases.  Dr. Peter McKeown, the head of the school here, gave an excellent lecture and tutorial on chest tube placement.

Of course, the students (and us) needed to practice placing chest tubes on something realistic, so Dr. McKeown and the rest of the staff here provided whole cow rib cages.  We set up a station right next to the rib cages where we were able to demonstrate relevant ultrasound.

“We just don’t have those resources in Nicaragua”

Today we received a tour of the hospital at UNAN, Leon in Nicaragua.  The hospital is pretty standard for Central America, with all the different divisions spread over 4 floors and doctors walking throughout the hallways at the usual brisk pace.  During our tour we walked into the pediatric unit, where we were greeted by an American physician.  Ellie is a third year pediatric resident at Duke who is performing an away rotation in Nicaragua as part of an exchange program.  She invited us into the pediatric unit, where 2 patients were stationed.  Ellie is a very competent physician, who cares very much for her patients.  However, working at a hospital in Nicaragua has demonstrated many challenges for her.  The hospital does not have a CT or MRI machine.  The closest machines are in Managua, 2 hours away, and are too expensive for most patients.  The perfect example is our first patient.

Priscilla is a young girl, about 2 years in age, who is suffering from a suspected interventricular septal defect and down syndrome.  Upon auscultation of her heart, the murmur could not have been missed.  Ellie told us that the diagnosis of Down Syndrome has simply been assigned to her, but no genetic testing or chromosome studies can be performed because of the lack of resources.  In the US, genetic testing would have been performed on a young patient with a septal defect and neurological symptoms, but not here.  The interventricular septal defect was also diagnosed solely through physical examination by Ellie.  We decided this would be a perfect time to inform her that we had an ultrasound machine with us, and we’re eager to help Priscilla and her family with the diagnosis.

Ellie was surprised that we had an ultrasound, as the hospital doesn’t even own a portable ultrasound.  We brought Priscilla into another room for an ultrasound, hoping to solidify the diagnosis.  Upon imaging, there was no doubt that she has a ventricular septal defect, but also an atrial septal defect.  The doctors, all surrounding our ultrasound machine, stared at the image for a few seconds before I asked Ellie when Priscilla would be able to get surgery.   Unfortunately, Ellie will not be receiving surgery.  The resources just aren’t available.  Ellie gave a prognosis of 2 years before Priscilla would pass away. I couldn’t help but imagine how different Priscilla’s life could have been if we were back in California.

It seems that sad stories about lack of resources are plentiful here.  Our second patient, 19 months old, looked the age of a typical 6 month old baby.  He was very malnourished, and Ellie informed us that instead of feeding him solid food, her mother was forced to continue breast feeding because food is too expensive for the family.  The baby was diagnosed with Kwashiorkor, a protein deficiency that is rarely seen in the US.  The baby was put on a steady diet and has been improving, however the baby had an open wound on his neck as a result from a “cut down” procedure that was performed at a different hospital.  When the baby was brought to Ellie, he not only had severe Kwashiorkor, but also had the open wound on his neck.  Ellie was told to close the wound with stitches, and was unable to give any pain medication.  When we asked if the baby was in pain, she replied, “Of course.  But that is just how things run down here. It breaks my heart.”  

Today was a harsh learning experience for me.  It may sound cliché, but i learned a lot about the differences between first world problems and third world problems.  Resources make a huge difference in the care that patients receive.  No genetic testing available for Priscilla.  no surgery available for priscilla.  No  help available for our Kwoshiorkor patient.  It was hard knowing the pathophysiology of our patients today, and not being able to do a single thing about it.  But as Ellie told us, “That’s just how things run around here.”

Great coverage of our students by the Stanford School of Medicine Scope blog

http://scopeblog.stanford.edu/2012/07/06/uc-irvine-medical-students-chronicle-experiences-working-overseas/

Inspect, auscultate, percuss, palpate, ultrasound

When Men lǎo shī is not in the operating room, he consults patient in the clinic. There are no secretaries or assistants so patients come into his office as they please. Sometimes there can be three different patients and their families waiting to talk to him.

This morning, out of the fourteen patients he saw, three of them came in to discuss their gallbladder polyps. Men lǎo shī showed me the ultrasound images of the gallbladder and pointed out the small polyps. When we go on rounds in the surgery ward with Men lǎo shī he’ll usually palpate and look for a positive Murphy’s sign. These patients clearly have pain in the upper right quadrant. With polyps this small, I wondered how the patient would even know that something was going on in the gallbladder. Do these patients feel abdominal pain? Discomfort? How would the doctor know to ultrasound the gallbladder specifically?

He told me that these patients are all worried because they had just come from their physical exam. It turns out that during a routine physical exam, physicans will inspect, auscultate, percuss, palpate and ultrasound the abdomen to examine the liver, kidneys, and gallbladder. (EKG, chest X-ray, and blood labs are also a part of the routine physical examination)

Ultrasound

Sorry, iPad

Admittedly, I was not a heavy iPad user throughout the school year.  Other than using it to read some textbooks or glance at the occasional anatomy flashcard, I hardly ever used it.  I found that a laptop accomplished nearly every task more efficiently.  Even when starting this trip I expected that it would mostly be used for Facebook, Angry Birds and, when I fell asleep in my hammock doing either of those two things, it could pass for a sun visor.

I have to say I owe iPad an apology.
Yesterday morning we found out somewhat unexpectedly that doctors from the community were coming to learn ultrasound techniques from us.  We panicked a little from the news, because, other than Michelle, our Spanish isn’t that great and we questioned whether our knowledge of ultrasound would even be useful for physicians in rural Nicaragua.
This is when iPad stepped in to the rescue.  Using screenshots of Dr. Fox’s podcasts and other images of ultrasound pathology, we created an impromptu powerpoint presentation on the iPads.  On one of the iPads we even added slides in between with text in Spanish that would serve as a script for the three of us gringos  (Jon, Alvin and me).   If there was anything we didn’t know how to say, we could simply open the google translate app, speak the word in English, and have it translated to Spanish for us immediately.
We were able to hand the physicians our iPads to follow along and look at the slides as we gave our presentation.  When it was their turn to operate the ultrasound we could show them a smaple image that they could try to replicate.  This style of presentation worked amazingly well!

The Dangers of Nicaragua

Hola de Nicaragua!

As Jon just posted, we made it! After all the meetings, research, planning, grant writing, IRB submissions.. we are finally here.   And even more, we made it in one piece!  Before we arrived, we accumulated a lot of advice about the dangers of travel in Nicaragua.  In fact, I’m going to list them all out.  Keep in mind, as unknowing gringos, these were genuine concerns of ours before arriving (except for maybe Edsel).

1. First and most importantly… Get the hell out of Managua!

Virtually everyone we talked to with any experience traveling in Nicaragua cautioned us to get out of Managua as soon as we land.. unless we were into getting kidnapped.  They suggested we all but sprint out of the airport and get into a taxi.  Which brings me to my next warning.

2. Don’t use the taxis.

That’s how you get kidnapped.

3. Don’t drive on the Managua-Leon highway.

So if we were lucky enough to find a taxi that didn’t want to kidnap three and a half gringos loaded with enough equipment to pay 10 nicaraguan salaries (no joke!), the only road out was the Managua-Leon highway.  According to the state department website, this road is the location of frequent roadside robberies in which assailants block the road with fallen trees and clean out tourists at machete point.  They then drive their unlucky victims to remote locations and drop them off empty-handed.

Luckily, we made it to our hostel without harm.   Unfortunately, the hostel is where we expected to face our most feared adversary…

4.  Spiders and other insects

Jon was kind enough to inform us of two types of tarantulas “prevalent” in Nicaragua (not cited).  First, there are the blue tarantulas.  These guys mean business.  Apparently, they climb trees, eat birds and are able to jump distances of up to 5 feet.

Then there are the hairy brown tarantulas.  These are the ones we were expecting to find under our hostel beds.  When you disturb them, they stand up in a defense posture and rub their legs together.  This rubbing causes the release of thousands of hair follicles that float through the air and cause painful rashes and even blindness.  Enough about bugs, but if you see Jon, ask about “bullet ants”, he loves to talk about them.

Avoiding all of these dangers could surely make one exhausted.  What better place to relax than to go lay out on the beautiful Nicaraguan beaches.  Wrong!

5.  Parasites in the sand

This warning came courtesy of my father via some ER physician who recently travelled to Nicaragua.  According to him, there are worms all over the beaches which embed themselves in a hosts skin and cause leishmaniasis (google it).  The only way to get them out is to use a matchstick to wind them out like spaghetti.  Sounds fun!

Nevermind relaxing, we’ll just go out to the rural areas and start scanning kidneys like we came here to do.

6. Malaria rampant in rural Nicaragua.

Finally there is something we are actually legitimately prepared to deal with.  We have mosquito nets, long sleeves, permethrin spray for our clothes, and 100% deet repellant (definitely carcinogenic).   We are also taking anti-malarial prophylaxis. Jon and I saved a few dollars buying the generic “mefloquine” which can cause odd dreams and even hallucinations.   No hallucinations so far!

 

In reality, Nicaragua has been far less frightening than we originally expected.  We’re getting used to constantly sweating from the heat and humidity, but it’s nothing that a cold, non-alcoholic cerveza can’t cure.

I have to run; we’re going to get food! Expect more soon!

-Andrew