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The Speed of Sound

The Speed of Sound

A Story of Ultrasound, Triage, and War

Butts, Christine MD

doi: 10.1097/01.EEM.0000578608.16347.9f
    ultrasound, triage, war, Iraq
    ultrasound, triage, war, Iraq:
    Dr. Abdullah Ibrahim supervising a house officer conducting a FAST exam.

    I met Dr. Abdullah Ibrahim in 2013 when I traveled to the semi-autonomous region of Kurdistan in northern Iraq for the first time. I quickly recognized him as a fellow ultrasound person after watching him demonstrate how to place a central line.

    Emergency Hospital, where Dr. Ibrahim works, was the de facto trauma center for Duhok and the surrounding region, but the principles of triage and organized assessment were practiced variably.

    Since then, I have returned every year and worked with Dr. Ibrahim extensively. But it wasn't until this year that I learned about his life, his training, and how changes to the local health care system took place. His story is one of personal growth and systemic innovation, and is interwoven with that of a small region confronting incredible challenges in emergency medicine and in war.

    Dr. Ibrahim said he realized he wanted to become a physician at a young age. He could not recall why, but he said he knew he wanted to be the first in his family to pursue medicine. He entered training, like many of his colleagues, with an eye toward general surgery. But he noticed a problem after three years of training.

    Trauma patients would arrive at the emergency department, but he and his junior colleagues were the only physicians present. There was no system in place for a standardized trauma evaluation. No one was available to intubate patients immediately. The only options were basic supportive maneuvers like suctioning.

    Flying Solo

    “No one, except the junior doctor, took care of the patients when they first arrived,” Dr. Ibrahim said. “I didn't have enough experience. When I received a trauma case, I didn't know what to do.”

    Dr. Ibrahim began creating his own trauma training program. He devised a program combining rotations in surgery, neurosurgery, radiology, and emergency medicine by relying on what he learned on the internet and from relief groups that visited the region. He was able to obtain support from some but not all of his faculty. The specialty departments didn't understand what he wanted to learn or how it would be beneficial to patient care, but he persisted.

    He attempted to obtain a diploma for his work, but was informed that they still weren't sure what type would be appropriate. Undaunted, he traveled to Italy, Lebanon, and Turkey to work with established trauma programs. Doctors Without Borders learned of his goals and sent two physicians to work with him in Duhok. He also received instruction from the U.S. Army in triaging and managing mass casualties.

    Dr. Ibrahim noted from his work with the Army that ultrasound was being used to evaluate trauma patients and thought it was crucial to implement it in his hospital. Initially, he encountered resistance. “When I went to the radiology department, I remember I told them I am here just to learn how to do the FAST ultrasound,” he said. “They told me we don't have a FAST machine.”

    The general director of the hospital eventually obtained an old ultrasound machine for the department, and Dr. Ibrahim roamed the hospital scanning any patients he could find. Over time, his skills improved, and he started training others. His cachet with his surgical and radiology colleagues also grew because his findings were proven right.

    Moving Forward

    Dr. Ibrahim now uses ultrasound in many clinical scenarios, including undifferentiated shock, shortness of breath, and suspected fractures. “The emergency physician, I think, when he is doing ultrasound in the ED [is] better than the radiologist, because of the clinical correlation,” he said.

    Over time, Dr. Ibrahim trained himself and the ED house officers and nurses in triage and trauma management. He said it was well known that the ICU was an easy place to work before these changes. Patients typically would not survive long enough to wind up there, resulting in an empty unit. After instituting triage and basic trauma evaluation and stabilization, however, the ICU filled up. Today, it cannot handle all the patients it receives, and they frequently spill over into other nearby hospitals.

    While Dr. Ibrahim was introducing trauma management and bedside ultrasound to Emergency Hospital, the prehospital system in the area was also struggling to develop. Both systems were put to an enormous test in 2014 when the Islamic State overtook Mosul, a city approximately 40 miles away. Emergency Hospital became the receiving center for thousands of war casualties. Imagine receiving up to 80 major trauma cases a day for months on end in your hospital, let alone in a hospital just beginning to implement trauma management.

    The Duhok area also absorbed enormous numbers of refugees and internally displaced people fleeing Mosul who became patients as well. The region's population, around one million prior to the conflict, doubled in just a few weeks.

    “In Iraq, we don't think about the future,” he said. Certainly, in an area where so many challenges remain, it can be overwhelming to think about what lies ahead. Only 4.7 physicians are available for every 10,000 people in Duhok compared with the world average of 14.1. The number of available hospital beds doesn't meet the need. Thousands of women caught in the middle of war struggle to deal with the physical and psychological aftermath of rape and human slavery. Large numbers of refugees still live in camps in the area, unable to return home. Despite these challenges, the system is moving forward. The steps that Dr. Ibrahim took to train himself are echoing through not just his hospital and medical school but throughout Kurdistan.

    Dr. Buttsis the director of the division of emergency ultrasound and a clinical associate professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter@EMNSpeedofSound, and read her past columns at

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