The city of Duhok has survived near-constant challenges over the past 30 years—attacks under Saddam Hussein's regime, civil war in neighboring Syria, invasion and occupation of the nearby city of Mosul and surrounding areas by the Islamic State. This city of about 350,000 people in northern Iraq and the surrounding area took in a huge number of refugees, first those fleeing from the Syrian civil war and then from the occupation of the Islamic State, nearly overwhelming local resources.
Efforts to drive the Islamic State out of Mosul began in the spring, bringing a new wave of casualties, pushing the health care system in this region almost to its breaking point in providers and resources.
I have had the good fortune to travel to this region every year for the past five years as part of a team of physicians dedicated to capacity-building in the region. As an academic physician in emergency medicine with training in ultrasound, I use it quite a bit here and there. Many physicians think using ultrasound day-to-day is time-consuming and bothersome and that it doesn't add a whole lot to patient care or the flow of a shift, but as my previous article, “A Day in the Life of Ultrasound,” showed, the daily use of ultrasound in a busy ED has a whole host of practical uses multiple times during even the most chaotic, hectic shift. (EMN 2015;37:12; http://bit.ly/2g1cd5R.)
Imagine how a day in the life of ultrasound looks in a place like Duhok.
One of the things that struck me on my first trip to the area was the determination of the Kurdish physicians to care for their people in the face of a huge increase in need and a rapid depletion of resources. When our team visited two years ago, Duhok and the surrounding rural area had seen an influx of 800,000 refugees. The physicians had not been paid by the central government in Baghdad for more than six months, and were working extremely long hours to handle the enormous medical and psychological needs of this potential humanitarian crisis.
Dr. Abdullah Ibrahim oversees an emergency department at Emergency Hospital that takes in a large number of trauma cases, from war casualties to the everyday injuries from falls and motor vehicle collisions. Initially trained as a surgeon and then in trauma care by the U.S. Army, Dr. Ibrahim was one of the first in the region to adopt bedside ultrasound and to teach it to his house officers and trainees. His work has been groundbreaking in how patients are evaluated and treated.
In many outlying rural hospitals, however, ultrasound is either unavailable or not a viable option because physicians have not been properly trained. Many times, physicians just out of medical school staff these hospitals, frequently as the only doctor in the building. They don't have formal education in evaluating and resuscitating trauma patients (including FAST exams), and they are often confronted with severely injured patients who need immediate care. Adding to this challenge is the fact that EMS is underdeveloped in Kurdistan and has no formal paramedic training. Many ambulances are staffed only by a driver, who may have no medical training at all.
Ultrasound as a Lifeline
The volume of patients has been high at Emergency Hospital. At the height of the war in Mosul, the physicians reported receiving more than 100 injured patients per day, and they regularly relied on the FAST exam to determine the severity of injuries. Other imaging modalities, such as x-ray, CT, and MRI were available, but the large number of patients made triaging their use more challenging. Dr. Ibrahim and his trainees, Drs. Heleen Aqrawi, Ruj Al-Sindy, and Mahmood Sh Hafdullah, related many cases in which a quick FAST exam identified injuries ranging from pneumothorax to intraperitoneal bladder rupture.
The use of ultrasound in Emergency Hospital has now expanded from FAST exams to nerve blocks (particularly femoral nerve blocks) and the RUSH exam for undifferentiated shock. One area in which ultrasound has proved to be useful is in evaluating distal radius fractures, especially in pregnant women, because x-rays are at times viewed with suspicion. Bedside ultrasound is popular with the patients, as it is in the United States, and many patients ask for a scan for reassurance.
I saw firsthand on my most recent visit how ultrasound was used and the difference it made in caring for patients who presented to Emergency Hospital. One case involving an unknown man found in the woods stands out to me. As with most of our patients in the ED, he presented as an unknown with an unknown story. It was even unknown whether he was friend or foe because IS fighters are known to flee the worsening situation near Mosul. In a matter of moments, it became clear that the man had been severely injured and was near death. Ultrasound was instrumental in identifying a complex intra-abdominal fluid collection and bilateral pneumothoraces. Once chest tubes were placed, ultrasound was again useful to troubleshoot a malfunctioning vacuum suction by identifying the continuing lack of pleural sliding. The patient's injuries were known long before a CT scan could be completed.
I use ultrasound every day in New Orleans as an extension of my physical exam and clinical judgment. Quickly confirming an intrauterine pregnancy in a patient with vaginal bleeding makes my disposition much faster and easier. A day in the life of ultrasound here is all about efficiency and patient safety, but for physicians like Dr. Ibrahim in Kurdistan, ultrasound serves a much more dramatic purpose day in, day out. With limited resources, a huge and growing number of patients, and the need to make quick decisions, ultrasound is a lifeline.