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Blog Entry from Peter Coombs 20.05.2019

End of week three. Let me tell you a little about Arba Minch. It’s a wonderful setting.

The town is built on the edge of

escarpment which separates the forest of Nech-Sar national park and Lakes Abaya and Chamo.  The streets are tree-lined. In the morning and evening they are vibrant with the activity of the people. They quieten a little in the heat of the date and constantly interrupted by the animal population which appears to have the rule of the town.

Arba Minch is a town of around 200,000 so isn’t large. It was only founded in the 60’s so in many ways it is remarkable in what has been achieved.  At the high end of town is a small business area with a diversity of business and hotels. There are a couple of resorts that have splendid views over Nech-Sar. The hospital is on the middle to lower part of the escarpment surrounded by and assortment or traders and Arba Minch

 

University buildings (pictured is my favourite coffee house). It always seems a hub of activity.  The lower part of town has two parts, split the Kulfo River. These lower reaches beyond the residential area are rich in fruit plantations (banana, mango guava and pineapple).  Arba Minch is a University town with over 1000 medical students studying at any time.

But… Arba Minch faces many challenges which are made worse by being rural.  Health is very high on the list and I have been touched deeply by this, every day I have been here. Some basic Ethiopian stats: Ethiopia is 3rd in Africa and 8th in the world for countries burdened by TB. Malaria is rife with over 1 million cases reported in 2007. The probability of dying under 5yo is between 58-112:1000 (Australia <4:1000)

And at this point I pause. The reality is that I have been less than comfortable writing this blog. The photo element is particularly difficult. While I don’t pretend to speak for the people of Arba, I am very sure they would only want to be portrayed as citizens of this planet trying to carve out their existence like anyone of us. My foremost interest is to respect this in word and pictures.

So why blog? WFUMB needs to be promoted for their wonderful work in supporting this initiative. Well done to Christian Pallson Nolsøe, Lynne Rudd and the wider WFUMB leadership.

Am also perpetually grateful to Philips for providing the Lumify portable ultrasound system which has been a godsend.

But the main reason I agreed to do this was that it would provide a platform where I could identify the needs and seek solutions. And this is the time.

Arba Minch needs ultrasound transducers so badly. Everyday we scan are scanning a very large number of patients. The images are degraded so badly. It’s a Samsung Sonoace X6 and we will take any transducers you have access to. I have asked before but now I am pleading.

Blog Entry from Peter Coombs 14.05.2019

It’s only the end of week two. It is hard to believe it is only two weeks. Most of the second week was spent working with the ultrasound team performing examinations and simultaneously training. Of note, early in the week I attended the O&G and surgical weekly case review meetings to promote the project.

In this update, I thought I’d describe the diversity of examinations that are encountered in Arba Minch. As mentioned previously, the lack of availability of CT or MR means that ultrasound is required to investigate, trauma and sepsis, both of which are extremely common in this locality. Perhaps to illustrate this diversity, here is an example of a morning spent in Arba Minch Hospital.

Last Tuesday morning was a particularly varied and challenging case mix. On arrival we found the usual 10-15 patients waiting at the door. At the front of the queue there was a woman lying on a trolley screaming in pain. As it turned out, she was 34 weeks pregnant and had a large mass above the gestation.  The diagnosis of a large incarcerated hernia was straightforward. Over the next 10 minutes this was gently reduced this with ultrasound guidance.

Over the next hour, we made three new diagnoses of malignancy (probable, cervical, gallbladder and metastases in the liver). Interspersed were  patients with relatively low level flank or epigastric pain or trauma. Mengistu and I then headed to the nursery to scan the abdomen and heart of a neonate with distension. (Note that I am not cardiac trained but extensive fetal echocardiography has provided basic skills in this area)

Following this we went to the pediatric ward and saw a young child with severe malnutrition (again distension and ascites). Amidst the ascites there was a very large ileal-ileal intussception which we decided we would review the following day to ensure that it had resolved. The stop was the O&G ward where we saw a woman with a large abdominal mass. We still need follow-up on this mass however it looked very much like a highly progressed partial molar pregnancy. And then finally to the medical ward to assess this man’s large empyema. The Philips Lumify has been great in facilitating this mobility.

Challenging, demanding but surrounded by caring professionals all going about their role to the level resources allow.

It’s important to note that it isn’t always like this. Like all clinics, there can be a run of normal ambulatory patients or routine obstetric surveillance. Nonetheless, the reliance on ultrasound and the socio-economic circumstance certainly create a setting for a diverse and interesting case mix.

Blog Entry from Peter Coombs 05.05.2019

Just checking in after my first week at Arba MinchIt has been quite a transition.   There’s so much to tell about my settling in and the early days Arba Minch Hospital. At the onset, I need to acknowledge the College Dean Dr Tamiru who has been wonderful in the lead up to the project and now in supporting me in these early days.

 In brief, I arrived early afternoon on Monday and spent the PM sorting accommodation and basic needs. Tuesday was  full day of scanning and I was immediately reminded why I felt it was important more support was provided.  Wednesday was a Festival Day so a day off!  Not really. Mengistu rang me to come to provide some on-call support  with some very difficult cases. These included a young woman with a massive neck abscess who was writhing in pain and a very sick young boy who had a sub-acute haemoperitoneum following a road accident 2 weeks prior. Thursday scanning in the main department. Friday I attended the weekly Internal Medicine meeting. The project was outlined by Dr Tamiru to the team encouraging junior and senior staff to make the most of any learning opportunities. After this meeting Mengistu and I headed to the special care nursery with the Philip Lumify.

However I am going to put this aside further detail for the moment and simply tell you about my re-acquaintance with the local sonography team. As previously mentioned, WFUMB ran a 4 day ‘Course in Abdominal Ultrasound’ in Arba Minch in which I participated as an educator/ trainer. Subsequent to the main program, I stayed on to provide additional ultrasound teaching. Most of this time was spent in the Imaging Department providing support for Katie (30 years experience), Mengistu, (newly graduated doctor) & Adimasu* (a young radiographer relatively new to the world of ultrasound).  

*Was very pleased to hear that Adimasu has subsequently taken an academic role in teaching radiography and basic ultrasound at Arba Minch University.

Our reunion was a joy. Huge grins. There were exclamations of delight that I had returned. Katie and Meningstu identified that they had been working hard on techniques and systems that we had established in the previous training. Their progress has been substantive. They were thrilled to get textbooks and the Philips Lumify which was put immediately into service. Was also introduced to Biniyin, a new member of the team.

The Arba Minch ultrasound service faces huge challenges. Patient numbers at times are overwhelming. Staff numbers and experience is low. The cases they see each day have significant complexity complicated by patients having an array of comorbidities uncommon in Western Health Care. Basic infection control seems impossible. And finally, this is a setting without CT or MR.  Ultrasound at times is the first and only imaging modality available to seek out a diagnosis. The case mix is quite something. 

Beyond these broad challenges, there is an immediate problem. The current installed ultrasound system  is a Sonoace X6.  This has been an excellent workhorse. It has two transducers. There is a linear 5-12 which has small amounts of artefact. However it is the low frequency curvi-linear that is desperately in need of replacement. It has a small cavity in the surface membrane and multiple areas of dropout. The artefact generated is highly problematic. 

Am wondering whether there is anyone in the WFUMB community who has transducers for the old Sonoace they would be happy to donate to a wonderful cause?

Blog Entry from Peter Coombs 27.04.2019

Last night in Australia before I embark. Had a lovely send off lunch with my colleagues at Monash Health Ultrasound yesterday .

At this time, I am just thrilled to have this opportunity to work with the team in Arba Minch. Packing for 6 months away does feel a little daunting.  Nonetheless, the first item in the suitcase is this Lumify Ultrasound System very kindly donated by Philips Ultrasound and facilitated by WFUMB. Thanks Philips. How amazing. Three transducers, a notebook (with a stand) all fits in that very small satchel. It will be a huge asset in my time away.  #arbaultrasound #WFUMB

Blog Entry from Peter Coombs 24.04.2019

In November 2018, WFUMB ran a 4 day ‘Course in Abdominal Ultrasound’ in Arba Minch, Ethiopia. An intensive training schedule for the local ultrasound service was provided as part of this program.  This was an exciting project where the benefits to the local team were considerable. Arba Minch Hospital has no CT, MR or a radiologist. As the team left, it was easy to see the importance of ultrasound and imagine the potential benefits to the sonographers and the hospital  of a much longer training program. From this beginning, project “arbaultrasound” was developed. 
 
Project arbaultrasound is WFUMB’s first medium length ultrasound training program in a developing country. The plan is for Peter Coombs, (a highly experienced sonographer from Australia), to support the Arba Minch Hospital & Arba Minch University as a clinical leader, trainer and educator for 22 weeks between May and October 2019. The main focus of the program is to provide training for the sonographers. There is broader ambition around supporting and expanding the use of ultrasound across the Arba Minch medical community. The project has support from the Australasian Society of Ultrasound in Medicine (ASUM) and Philips who have provided a Lumify to support the clinical activity and teaching of the program.

Over the coming months Peter will provide updates on the progress of the program and the give us some insight into the community of Arba Minch. You are welcome to subscribe to this blog if you are interested in the program or wish to support WFUMB’s activities in this area. It may also be of interest if you are ultrasound professional with ambition to volunteer for similar projects. Peter can also be followed on Twitter using #ultrasoundarba #WFUMB

 

 

 

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