Week 2 with Jo McCann in Mekele, Ethiopia.
My base for the two weeks has been the Mekelle University Ayder Referral Hospital in the Tigray region of Northern Ethiopia. The hospital has 500 beds serving a population of approximately five million people. Amharic is the national language of Ethiopia but there are over 80 languages and 200 dialects spoken throughout the country which can make it quite challenging. Tigrinya is the local language, However, fortunately for me, English is the language used for medical records. Whilst I was visiting Ethiopia, it was February/March 2012 as they follow their own calendar based on the Julian calendar which was confusing initially when reviewing previous ultrasound reports dated 7.5 years ago which turned out to be only two weeks ago.
My home for the six days hands on training was the Gastroenterology and Hepatology Unit with forays up to the Internal Medicine wards and the Intensive Care Unit for portables. There was a steady stream of patients through the clinic, although I am told the hospital is quiet due to it being harvest time and everyone is needed to help at home.
The most striking difference for me was the advanced state of disease on presentation, which then makes it much harder to treat. Small shrunken livers with advanced cirrhosis, ascites and splenomegaly were very common in relatively young patients with hepatitis. It was sad to see two patients who were 19 years of age but looked many years younger, due to being malnourished from schistosomiasis infection and its effects on the body. This disease could be prevented by yearly worming. The prevalence of untreated H-pylori makes gastric cancer very common.
Scanning on the wards is challenging; bright sunlight pouring in large uncurtained windows prompted patients and residents to try and shade the ultrasound machine. Limited presets and a curved transducer provided many valuable teaching opportunities on machine optimisation.
I taught the ‘6+’‘method of scanning the abdomen, which gave the doctors a structure to follow, helped the doctors attain basic ultrasound skills quickly and allowed for reinforcement throughout the sessions. I was also able to expand on this once the basics were mastered, and I am confident that we have left the department with improved ultrasound skills and a framework to teach other ultrasound users. Everyone I met was grateful and also eager to learn. One of the highlights was my final teaching session on Saturday morning with off duty residents who came in specially to have uninterrupted time to learn. After a wee while, I noticed they were teaching one another and I took a back seat and allowed them to run the session- it was magic!
My trip to Ethiopia was challenging but very rewarding and I hope that I was able to pass on my enthusiasm for ultrasound and helped increase the local skillset, which will benefit the patients who are the reason we do what we do. I would like to thank WFUMB for the opportunity and the doctors at Ayder Hospital for their eagerness to learn and acquire ultrasound skills.
Jo McCann, a sonographer from New Zealand volunteered to attend a WFUMB course in Mekele, Ethiopia, organised by
Odd Helge Gilja and assisted with lectures during this week. Jo is staying on for one week to hold a workshop to follow up
offering hands-on training.
This is Jo’s perspective …
We started the week strong with 30 attendees for our first day of lectures and hands on training with a mix of internal medicine doctors, paediatricians, cardiologists and emergency doctors. They came and went depending on their commitments on the wards or examinations. However, what never changed was their enthusiasm to learn new skills and extract as much information from us as they can. The four formal days gave them a real taster for what you can use ultrasound for, and many were surprised by images of tonsils and cortical breaks in bones to name just a few.
I have stayed on to give one on one training to really polish their ultrasound skills. It’s been a lesson for me as well on how to optimise the ultrasound settings when trying to get flow in the portal vein on a cardiac machine.
There are several ultrasound machines on the wards each with its own user challenge. The general medicine and ICU portable machine do not have the ability to use colour Doppler, one of our trusty techniques. If the patient is referred for a formal ultrasound there is a 7-10 day wait.
The word is out that a sonographer is here and willing to help. Although assigned to one doctor per day this swells to more once they know where to find me. We have had a mix of patients in the gastroenterology clinic with hepatitis B, gastric carcinoma and mild to severe forms of cirrhosis. Their machine has Doppler which helps immensely in enabling us to assess portal vein flow and varices.
Next was up to the general medicine wards to assess patients with TB for lymphadenopathy. Again, no Doppler on this machine and a hole in the transducer membrane but luckily no elements out so we could still get a reasonable image. Infection control is a challenge here with wiping the transducer with a tissue considered adequate. Running water can be difficult to source, gloves and hand sanitiser keeps my hands clean between patients.
We were called to scan a submandibular and parotid gland in the ICU and arrived to find a curved transducer, abdominal or obstetric presets and no ultrasound gel. You quickly learn to adapt and also be grateful for what we have at home.
It’s been a busy week, but one filled with admiration for the local skills and willingness to embrace new learning and gain new skills. It is a very humbling experience.
Blog Entry from Peter Coombs 16.10.2019
Remarkably this is my final post from Arba Minch Ethiopia. The time has been professionally and personally very rewarding. Have learnt so much about ultrasound, medicine, life and faith.
Before, I reflect on this time, some acknowledgements. The team at WFUMB (Dr Christian Pallson Nolsøe, Lynne Rudd) have been spectacular in their overall and day to day support, Suzanne Cain (Kosmos Design) for blog design & ASUM (Lyndall McPherson), my local society have also been great. And a big shout out to my colleagues at Monash Health for the leave and encouragement (esp Frauke Lever who has performed my role). In Arba Minch, Dr Tamiru Degaga (Dean of Medicine), Dr Tadiwos Hailu & Dr Aynelam have provided marvellous leadership. And the last one, Sharon Carnell, my partner, for her immediate and unconditional support for the project from the moment it was raised.
All up, the project has been very successful. New technology has been introduced thanks to the generous support of Philips Healthcare, Quantum Health Care and Samsung Global. There has been considerable ultrasound training. The main recipients were the local sonography team (Katie, Mengistu and Biniyan) but I spent time with various clinicians across this time (see pictures). New ultrasound examinations were added, and mobile ultrasound became a reality. There was considerable shared learning as the local team learnt about the patterns of practice (eg. infection control, patient care) from my institution and I experienced theirs. Late in the project, a fundraising campaign out of this project, raised a large sum of money for the Arba Minch Children’s Ward.
Add in a research project, some wider teaching and you can see it was a productive time. Beyond all of these advances, it is the day to day clinical impact that a sonographer can make in each examination that feels the most important. But there is more …
Mentioned a few times that confidentiality precluded individual patient stories and photos on this blog. This has been heart wrenching for me as the real impact of my time, is told through these individual stories. Because of socio-economic and geographic reasons, many patients here present much later than they would in my own institution. Neoplasia is often far more progressed and the infections, so large. While there is an opportunity for clinical curiosity, this rapidly gives way to clinical concern and despair. As I have mentioned previously, there is no CT or MR in Arba Minch. Ultrasound is such an important diagnostic tool. The ultrasound professional community has an enormous opportunity and an obligation to contribute to the health status of developing countries by supporting ultrasound training projects like this. Let me implore you to make this a priority by either contributing as a volunteer or by donating to an outreach program.
The final word is a heartfelt thanks to the local team for their unyielding acceptance and friendship across the time. Am torn to be leaving them.
Blog Entry from Peter Coombs 08.10.2019
There is much about the project that I have been thrilled about. Outstanding on my ‘to do’ list was to get involved in some research..
In my own mind though, I was disappointed that I hadn’t made ground on a substantive project. For some months, I have been chatting to Dr Tadiwos (great supporter in my time here) about this possibilities in this area. Truth is that I had decided it would never happen.
Am very excited that it finally came to fruition last week. The project involved scanning the abdomen of the adult population of three communities in Konso. Having access to the Philips Lumify meant we could travel to Konso and actually scan in the local setting. The communities are part of a bigger study relating to their diet. Each community is unique in its own way. The scan settings were remarkable as you will be see in the photos.
Blog Entry from Peter Coombs 23.09.2019
Last week, I took a week out of my usual routine at Arba to head down to the Aga Khan Hospital in Nairobi.
Blog Entry from Peter Coombs 22.08.2019
Blog Entry from Peter Coombs 24.07.2019
Another “Hi” from Arba Minch. It’s the cooler season here with sporadic rain. There is some seasonal change to the fare available at the local markets. (eg mangoes have been replaced by apples). Regional violence is causing long outages to internet which is causing a few communication issues and is part of the reason I have been a little slow with these updates. Limited communication and limited time to travel has also meant that my Ethiopian experience is contained to this local region. Let me tell you a little about this and the people I meet.
Arba Minch is a productive agricultural area meaning that it does well by local standards. It is a region that is not prone to famine. It is a major university town which supports the economy. This means ultrasound supports a diversity of people. The town population that resides here has ultrasound needs that we see across the world. Let me make some generalisations. The service is overrun with mid-range abdominal pain, obstetric care, evaluation of chronic liver disease, multi-nodular goitre, women’s health (breast and gynaecology) etc. This isn’t so different to home. Even some of the predisposing factors such as HBV, HCV and alcohol that I see at home are common here. Having said this, patients tend to present later, get sicker younger and the opportunity for follow-up and surveillance is less.
And there are major differences. There is no musculo-skeletal ultrasound here for low or mid range pain tendon and joint pain. The MSK we see tends to be serious conditions such as neoplasia or sepsis that has progressed to osteomyelitis. Without a CT, Ultrasound is used much more extensively for trauma (eg Road trauma) and complicated chest evaluation. The Philips Lumify has been really valuable in extending this service in my time here. The other obvious difference are the pathologies encountered commonly here include TB, Malaria, HIV, Leishmaniasis and Ascarias.
But Arba Minch Hospital is a “Regional Referral Service”. Geographically it supports more than the local town. Its care extends into the poorer mountain populations and to the south, rural and tribal people. The patients who come from these areas, present even much later with sometimes, disturbing consequences. Malnutrition is commonly encountered in children. Very late stage cancer presents in the adult population. And some terrible infections. Recently, I travelled into the south and visited some of the tribes. This provided some valuable context and insight as to how and why this is happening.
But I commenced this entry with an acknowledgement that my Ethiopian experience is only regional. The May 2019 UNICEF Ethiopia Humanitarian Situation Report
provides disturbing insight to the challenges faced across the country. Please take the time to read this and reflect on the disparity between your own human experience and that of nations through this region. Maybe with WFUMB 2019 rapidly approaching, ponder how you can contribute to the outreach effort of your local society or WFUMB Outreach. You don’t need to travel across the world to impact and care for these people.
Blog Entry from Peter Coombs 04.07.2019
Greetings from Arba Minch.
Apologies that I have been relatively quiet in recent times. It has been a difficult time in Ethiopia. An attempted coup has seriously limited communication in and out of the country. This has certainly hindered my capacity to update this blog regularly. But…
Exciting news in this update. Two new transducers have arrived in Arba Minch. Yes two !
Firstly a huge ‘shout out’ to the team at Quantum Healthcare in Australia. Quantum provide Samsung equipment to the Australian Ultrasound Community.
Quantum Healthcare have donated a micro-convex C4-9 transducer to the team at Arba Minch Hospital. This is outstanding for a wide range of work but particularly paediatrics. Paediatric renal examinations and assessment of bowel (eg appendix) will be vastly improved. This will also provide the opportunity for transfontanellar intracranial sonography in the neonates which hasn’t been previously available.
Thanks Tiffany Chew (General Manager QUANTUM HEALTHCARE ANZ) and all your team. This is greatly appreciated.
And then a second ‘massive thank-you’. Samsung International have replaced the badly damaged curvi-linear low frequency transducer with a C2-5 transducer. The improvement to the overall imaging in all areas is phenomenal. No longer are we fighting large bands of artefact in our ultrasound images. The improvement we are seeing in the Obstetric and Chest Abdominal imaging is especially appreciated
Thanks Nukky Shin, SAMSUNG MEDISON : APAC Managing Director for facilitating this.
One of the transducers was hand delivered by my partner Sharon. This was exciting for the ultrasound team (pictured) who presented Sharon and I with traditional scarves. In the other photos you can see Katie, trailing the new C4-9 and Bini, celebrating the arrival of the C2-5
Suffice, to say, these two donations will be transforming for the department.
Thanks again Samsung, Quantum and the team at WFUMB. Look forward to communicating more about this.
Blog Entry from Peter Coombs 05.06.2019
Am keeping quite busy through the week. Its difficult to tell specific clinical stories because of the need to preserve patient anonymity. Here is a brief clinical reflection which is kept quite general for this reason.
It is a unusual occurrence but one of the paediatricians gave me a call to perform a scan on a very sick child suffering from cardiogenic shock. The scene upon which I arrived was of a large number of clinicians working feverishly to do everything they could do. In the space between arriving and being needed, I had a few minutes to watch on in admiration. What struck me was the similarity between what was going on here and what goes on in hospitals across the globe. The settings are different, but the intent and skills are virtually the same.
And then it was my turn. A focussed cardiac scan to quickly consider major cardiac dysfunction and a survey of the abdomen and chest to look for a source of sepsis. There is no mobile x-ray in Arba so there hadn’t been a chest x-ray at this point. The chest ultrasound showed collapse and consolidation bilaterally with effusions (see image). The poor child was battling serious pneumonia. In probably 10 minutes I was done.
Subsequently, I stayed around and watched and chatted to the team. It crossed my mind as I was standing there, what a phenomenal tool the ultrasound system is. It provided so many answers, at the bedside and in a short time. In this instance, the system was an ultrasound transducer that plugs into a tablet. Quite something ! This is energising to someone who has been in the profession for decades and will be the experience of many who take on volunteer roles.
But foremost in my mind was health of the young boy. This setting will present him major challenges.
Blog Entry from Peter Coombs 27.05.2019
Busy clinical week here with a number of demanding and complex cases.
The work at Arba certainly pushes the limits of your skills. Among the cases I scanned were a neonatal cranial for IVH, a neonatal heart looking for congenital heart disease, an adult heart severely affected by chronic pulmonary hypertension, a complex venous insufficiency study on a woman with a AV malformation on her leg and far more bowel and lung work than I am used to doing at Monash because of the availability of CT.
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
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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