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The Speed of Sound

The Speed of Sound

The ‘Why’ of Ultrasound

Butts, Christine MD

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doi: 10.1097/01.EEM.0000459709.19538.8e
    The resuscitation bay in the Emergency Hospital ED in Duhok, Iraq.

    I typically write my columns about the “how” of ultrasound, but it's also important to think about the “why.” Ultrasound to me is a tool that can be shared across cultures and barriers to broaden education and to improve patient care.

    So when a colleague approached me about teaching ultrasound in Kurdistan, Iraq, I was intrigued. Nervous but intrigued. I have been teaching ultrasound to residents, students, and other faculty here in the States for almost seven years, but have always harbored a desire to teach internationally.

    I spent two months as a medical student working in a hospital in Zambia, and had experienced firsthand how devastating a lack of resources and knowledge can be. I was hopeful that bringing my experience with ultrasound to underdeveloped regions would empower local physicians to improve the care of their patients. Since that first anxious trip to Iraq, I have had the opportunity to teach in Kurdistan twice and also spent three weeks this summer working and teaching in an ED in Haiti. Ostensibly, I went to these regions to teach, but I also learned a great deal about ultrasound and its place within emergency medicine.

    Twenty-four hours into my first trip to Kurdistan, Iraq, I was reminded of just how far from home I was. Patients surrounded our small group, holding copies of blood work, CT scans, and MRIs. Looking through the information they held in their hands, I saw that most of them had undergone appropriate workups and were on the appropriate treatments. Our evaluation of their workups seemed to reassure them because we were “American doctors.” I wrote prescriptions for medications, crutches, wheelchairs, and, in one strange circumstance, a house. It was certainly a far cry from my day-to-day job of teaching emergency medicine and ultrasound here.

    I spent most of my time in Kurdistan teaching surgeons and internists because emergency medicine is not yet a separate specialty. The physicians I encountered there were adept and capable in their respective specialties, but the idea of using ultrasound at the bedside to evaluate critically ill patients and to augment the physical exam was foreign to them. They accepted its use in the FAST exam and for guiding central lines, but my suggestions to use ultrasound to evaluate the soft tissue of a patient with skin changes or the lungs of a patient with undifferentiated shortness of breath were met with quizzical responses.

    Surgical residents practicing their FAST skills in Duhok, Iraq.

    The Kurdistan emergency departments are staffed by internists at one hospital and surgeons at another. The concepts that we hold dear as emergency physicians, such as triage and rapid evaluation and treatment, were not universally evident. Seeing people wander through the ED at will and having to push my way through a group of family members surrounding the bedside of a critically ill patient was culture shock.

    I was encouraged that trainees I met on my initial visit, however, shared cases in which they used bedside ultrasound when I returned a second time. Many physicians, particularly those in training, were intrigued by the idea of point-of-care ultrasound, but I realized that the concept of bedside ultrasound was as foreign as the concept of emergency medicine as its own specialty. It seemed on my return visit that some inroads had been made because the skills used to evaluate critical trauma patients had been passed from my initial trainees to a new group of residents. Some reluctance still remained, however.

    Both places are very hot, but you couldn't find more different cultures than Kurdistan and Haiti. Emergency medicine is a burgeoning specialty, and the trainees were eager to learn ECHO, FAST, and pulmonary ultrasound. I felt a real satisfaction in seeing them grasp the concepts and put them to use, at times in diagnostically challenging cases such as undifferentiated pelvic masses or strangely dilated loops of bowel. I was frequently reminded of my limitations by theinability to act on the diagnoses that were made. A case of pyomyositis that was identified and aspirated with ultrasound guidance had me on top of the world until the news that the patient had died shortly after surgical debridement sent me crashing back to the ground. Despite these challenges, seeing a trainee get a look of understanding was as fulfilling as it is here in the States.

    But these young doctors had learned to think like EPs, and they were able to understand how a quick cardiac exam might be beneficial in a hypotensive patient or how evaluation of the soft tissue might help to distinguish septic bursitis from a septic joint. Fittingly, this fall, the hospital will launch its first class of emergency medicine residency trainees.

    Point-of-care ultrasound has great power to improve medical care in areas lacking resources. Lack of equipment, meager financial resources, and lack of proper training are barriers to its integration. But failure to incorporate the basic concepts of rapid evaluation and treatment may prevent the widespread adoption of point-of-care ultrasound in areas where emergency medicine has not yet been established as a specialty.

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