Having traveled and worked in under-resourced settings before, I thought I had some idea of the type of clinical situations I would be encountering while teaching in Masaka, Uganda with the Global Emergency Care (GEC) program. However, during my three weeks at the Masaka Regional Referral Hospital, I was continually amazed by the breadth and acuity of conditions seen by the medical officers (MO’s) and emergency care practitioners (ECPs) in the Accident & Emergency (A&E) department. They managed some of the sickest patients I have ever seen with foley catheters for chest tubes, only four oxygen wall regulators, one intermittently functioning defibrillator, and minimal IV medications. It was exciting to watch the ECPs utilize clinical and ultrasound knowledge acquired through their diploma program to direct and improve patient care.
Take, for example, the 20-year-old man who presented with proximal right forearm swelling. He had been stabbed in his forearm, just below the elbow, at the beginning of January (over two months ago). He had presented to the hospital immediately after the injury, and had the wound closed with stitches at that time. Sometime in the next two months, he started to notice right forearm swelling and pain. He had no fevers, and there was no obvious infection around the original wound. The swelling bothered him enough in late March for him to present for medical attention. The first medical officer to evaluate him was concerned that he had an abscess under his skin, so sent the patient to the A&E for them to cut open his forearm.
When first evaluated by one of the senior ECP graduates named Alfunsi, he recognized that something wasn’t right about this story. Alfunsi elected to put his ultrasound skills to use.
Upon placing the ultrasound probe on the patient’s forearm, he immediately realized this was not an abscess; the fluid collection didn’t look right. When color flow was placed on the large, round fluid collection, the fluid was pulsing! This was, in fact, either a pseudoaneurysm or aneurysm of the radial artery with a fistula between the cephalic vein and radial artery. In essence, the knife wound in January had poked a hole in the artery in the patient’s upper forearm and connected the artery to the nearby vein. Every time the artery pulsed, it had been pushing blood into the vein and the surrounding soft tissue. These ultrasound findings were reinforced by the fact that the patient had only a very faint pulse at his wrist near his right thumb (the distal radial artery), but a very strong pulse in his left wrist. If Alfunsi had cut open this wound, it would have bled all over the room, and the patient could even have lost his arm. Instead of antibiotics or cutting open the swelling with a scalpel, this patient needed a vascular surgeon to repair the artery and vein.
Alfunsi and the other ECPs took the initiative to call over the intern physician to explain the case. After reviewing the ultrasound findings with the ECPs, the intern agreed with them; this patient needed to be referred to a vascular surgeon. Since there are no vascular surgeons in Masaka (the hospital, in fact, does not even have a CT scanner, let alone sub-specialists), the patient was referred to a surgeon in Kampala. I realized that by spending a few extra minutes evaluating this patient with bedside ultrasound, Alfunsi may have saved this man’s arm.
This was one of many cases I witnessed in the Masaka A&E where ECP clinical knowledge and ultrasound skill greatly improved patient care and outcomes. It is incredibly powerful and fulfilling to watch expertise you have shared with ECP learners be directly translated into clinical care. In my experience, this information-exchange is the most impactful in incredibly under-resourced locations like Masaka, Uganda. Even small changes in knowledge base or imaging availability (i.e. having a bedside ultrasound available in the A&E for ECPs to use) has a huge impact on patient care, community health and system-wide practice. I am so grateful to the staff at the Masaka Regional Referral Hospital for sharing their enthusiasm and ingenuity with me during my time in Masaka, and so excited about the work that GEC is doing to help empower the medical community in Uganda.
Dr. Leigha Winters