|Year : 2016 | Volume
| Issue : 3 | Page : 14-17
Republication: Utility of hand held portable ultrasound in a rural Guatemalan hospital
Frank Madore1, Erika Kube1, Stanislaw P Stawicki2, David P Bahner1
1 Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH, USA
2 Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Medical Center, Columbus, OH, USA
|Date of Submission||21-Mar-2016|
|Date of Acceptance||04-Sep-2016|
|Date of Web Publication||19-Aug-2016|
David P Bahner
Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210
Source of Support: None, Conflict of Interest: None
Ultrasound has been used extensively in the medical setting in the so-called first world countries and has become a more affordable, portable diagnostic tool. Medical care in more austere environments may not have access to all of the diagnostic technologies currently available in first world countries. During a recent medical mission to Guatemala, portable focused ultrasound was used in the medical setting to help with clinical decision making. Portable ultrasound in austere medical environments has technical challenges unique to this environment, yet can help the clinical team in their management of various patient complaints.
The following core competencies are addressed in this article: Medical knowledge; Patient care; Practice based learning and improvement; Systems based practice.
Republished with permission from: Madore F, Kube E, Stawicki SPA, Bahner DP. Utility of hand held portable ultrasound in a rural Guatemalan hospital. OPUS 12 Scientist 2011;5(1):1-3.
Keywords: Clinical decision making, diagnostic imaging, focused bedside sonology, portable ultrasound, rural setting
|How to cite this article:|
Madore F, Kube E, Stawicki SP, Bahner DP. Republication: Utility of hand held portable ultrasound in a rural Guatemalan hospital. Int J Acad Med 2016;2, Suppl S1:14-7
|How to cite this URL:|
Madore F, Kube E, Stawicki SP, Bahner DP. Republication: Utility of hand held portable ultrasound in a rural Guatemalan hospital. Int J Acad Med [serial online] 2016 [cited 2020 Jan 19];2, Suppl S1:14-7. Available from: http://www.ijam-web.org/text.asp?2016/2/3/14/188731
| Introduction|| |
Physician-performed bedside sonography has proven to be a valuable diagnostic tool in the emergency department, other hospital settings, and has been helpful in both prehospital and field settings.,,,, Due to the increasing portability of ultrasound systems, their low-cost profile, and the fact that no ionizing radiation is involved, many investigators have begun to evaluate the utility of portable ultrasound in more austere environments such as the field hospital following natural disaster, forward surgical teams near military battlefields, and even in the outer space. Several observational studies have been carried out to assess the utility of the technology in developing countries with limited access to diagnostic imaging. Reported experiences include the use of ultrasound in the Amazon jungle, medical clinics in Ghana, and following a mudslide in Guatemala. In those series, portable ultrasound was demonstrated to be a highly useful tool in making simple but vital diagnoses.
The goal of the current project was to add a new contribution to this scant overall body of literature. The authors describe using a simple, hand-held ultrasound machine for a variety of clinical applications during a 4-week global health initiative in a rural Guatemalan hospital with no routine bedside ultrasound capabilities.
| Materials and Methods|| |
In April 2009, a 4th year medical student traveled to Cuilapa, Guatemala as a participant in a global health initiative at the Hospital Regional de Cuilapa, Santa Rosa. A SonoSite iLook 15 (SonoSite, Inc., Bothell, Washington, USA) with a 5.2 MHz curved array transducer and an ample supply of ultrasound gel were transported to the clinical site. All ultrasound scans were performed by a 4th year medical student with 3 years of ultrasound experience and more than 250 ultrasound scans completed before this study. The student's rotation at Hospital Regional was divided between the general medical and surgical services. The ultrasound machine was available both on general hospital wards and in the emergency room. In both clinical environments, patients with complaints or conditions that might be elucidated with sonography were identified. In some cases, ultrasound scans were performed on patients with a known condition for educational and/or research purposes. In either case permission for the scan was obtained from the team leader (generally a resident) and consent for the scan was obtained from the patient. A “scan” of a certain organ was defined as at least one image of that organ. Two different views of any organ covered in the focused assessments with sonography for trauma FAST exam defined a separate “scan” of that organ. Due to the limited memory capacity of the iLook 15 portable ultrasound machine (74 images) only abnormal findings were saved to the machine's memory. Data were further documented on an ASUS EeePC (ASUSTeK Computer Incorporated, Taiwan) using OpenOffice.org 3.0 (Sun Microsystems, Inc., Santa Clara, California). Recorded clinical endpoints included: (a) Ease of image acquisition, (b) appropriateness of the machine for the attempted examination, (c) pathology discovered or ruled out, and (d) changes in patient management due to information gained with ultrasound examination.
| Results|| |
A total of 36 scans [Table 1] were performed on 20 patients during 3 weeks period: 9 FAST, 4 renal, 3 cardiac, 3 hepatobiliary, 3 appendix, 2 lung, 2 bladder, 2 aorta, 1 each obstetric (transabdominal), gynecological (transabdominal), internal jugular (procedural), inferior vena cava (IVC), deep venous thrombosis (DVT), ocular, spleen, and bowel. Clinical utility of each study was rated subjectively by the operator as either technically adequate (capable of answering the clinical question almost definitively), helpful (capable of providing useful information in answering the clinical question, but not without some doubt), and inadequate (of no benefit in answering the clinical question). In 11 (55%) of the patients, the studies were felt to be technically adequate, in 7 (35%) of the patients, the studies were felt to be helpful, and in 2 (10%) of the patients the studies were felt to be inadequate.
|Table 1: Summary of types of ultrasound studies, indications, and associated findings in the current series|
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| Discussion|| |
In the setting of a small hospital in a developing country, hand-held portable ultrasound was a useful tool in aiding with the diagnosis and management of a number of patients. In a setting where bedside ultrasound is not available, there is a great need for such imaging capability. The iLook 15 was particularly useful for basic, gross scans such as the FAST scan (identifying intraabdominal free fluid), urinary tract imaging (identifying hydronephrosis or bladder enlargement), cardiac imaging (such as cardiac motion, pericardial effusion, obvious decrease in contractility/congestive heart failure), and simple, large measurements such as abdominal aorta, IVC, and kidney.
The machine was limited in its ability to perform more detailed exams such as ocular, appendix, IVC collapsibility index 2, 5, lung (pulmonary), DVT, and obstetrical/gynecological exams for a few reasons. First, the machine comes with only one probe (5.2 MHz curved array transducer), which is not removable or interchangeable and the minimum depth of penetration is 4.9 cm. A high-frequency or endoluminal probe would have been required to perform some of the exams attempted with the curvilinear probe. In addition, the machine lacks M-mode, which is essential for making measurements such as fetal heart rate or IVC compression index, as well as confirming and documenting findings such as pneumothorax or lack of cardiac motion.
Another limitation was that the resolution of the machine's images is fairly poor compared to some of its larger, but still portable counterparts, and the color Doppler mode was unreliable. The machine was also unable to save video, limiting the ability to share dynamic findings such as those in the heart and lung. Image labeling was also difficult because pictographs were not available and there were no labeling tools. The machine cannot store more than 74 images, and the images cannot be readily off-loaded from the machine by any universally available means such as USB memory key, flash memory card, or USB connection to a computer. The battery life of the machine was also a limitation as it would last about 10 min and then would require significant downtime for charging between scans. It is expected, however, that a new battery should last 20–30 min, so this was likely due to the age of the battery that was used. In addition, lack of a zoom feature and inaccurate positioning of calipers limited the ability to make small measurements, such as the gall bladder wall.
Despite the challenges of the equipment, the resolution, and the connectivity, we found portable ultrasound machine to be a useful tool in a variety of clinical cases. There were many limitations to this project. First, the design is very informal, which limits the number of conclusions – specifically the external validity – that can be drawn from it. Second, this was an observational study using a convenience sample. Only a small number of patients were examined, and most scans were only performed a few times, leaving the conclusions based on such small sample sizes very challenging to make.
However, when comparing the capabilities of the iLook to previous scanning experience (mostly with the SonoSite MicroMaxx) it quickly becomes clear what types of scans are still possible and what types are not. Such a machine, while still portable, may be more appropriate for the hospital environment where the technology does not necessary need to be handheld. A more full-featured machine, while slightly more expensive, would likely be more cost-effective as formal imaging could be avoided in more cases. The use of more sophisticated ultrasound equipment would likely improve management as more diagnoses could be definitively made.
Considering the possible future applications for this study, it would be of interest to compare multiple handheld and portable ultrasound machines in more hospital and rural settings. Studies could be done to evaluate the cost-effectiveness of portable ultrasound in areas with little access to care, which may support future global health efforts. With enough evidence, governments and organizations that support global health may be motivated to raise funds to donate or subsidize portable ultrasound machines and train personnel in many developing countries, improving patient outcomes in environments that lack other diagnostic imaging modalities. Although the equipment used in this study was limited in its technical capacity, it was still an advanced tool in this remote setting. Future programs with medical missions to austere environments may want to incorporate portable ultrasound into the clinical experience as it can help deliver clear images to the bedside practitioner.
| Conclusions|| |
Portable ultrasound can be a useful diagnostic tool in a setting where advanced imaging is not readily available. A handheld unit with limited capability such as the iLook 15 can assist the clinician in confirming a variety of important diagnoses or to quickly rule out suspected critical conditions. However, a machine with a few additional key features, including auto optimize/auto gain, tissue harmonics, and cine storage would greatly improve the clinical utility of this diagnostic modality.
Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Busch M. Portable ultrasound in pre-hospital emergencies: A feasibility study. Acta Anaesthesiol Scand 2006;50:754-8.
Stawicki SP, Braslow BM, Panebianco NL, Kirkpatrick JN, Gracias VH, Hayden GE, et al.
Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: Correlations with CVP. J Am Coll Surg 2009;209:55-61.
Blaivas M, Kuhn W, Reynolds B, Brannam L. Change in differential diagnosis and patient management with the use of portable ultrasound in a remote setting. Wilderness Environ Med 2005;16:38-41.
Melanson SW, McCarthy J, Stromski CJ, Kostenbader J, Heller M. Aeromedical trauma sonography by flight crews with a miniature ultrasound unit. Prehosp Emerg Care 2001;5:399-402.
Stawicki SP, Howard JM, Pryor JP, Bahner DP, Whitmill ML, Dean AJ. Portable ultrasonography in mass casualty incidents: The CAVEAT examination. World J Orthop 2010;1:10-9.
Alson R, Alexander D, Leonard RB, Stringer LW. Analysis of medical treatment at a field hospital following Hurricane Andrew, 1992. Ann Emerg Med 1993;22:1721-8.
Parker PJ, Adams SA, Williams D, Shepherd A. Forward surgery on operation telic – Iraq 2003. J R Army Med Corps 2005;151:186-91.
Dean AJ, Ku BS, Zeserson EM. The utility of handheld ultrasound in an austere medical setting in Guatemala after a natural disaster. Am J Disaster Med 2007;2:249-56.
Spencer JK, Adler RS. Utility of portable ultrasound in a community in Ghana. J Ultrasound Med 2008;27:1735-43.