Point of Care Ultrasound in Rwanda : A few interesting cases.

Case 1:  Last week, we had a patient who presented to the emergency room booked as heart failure.  He was transferred from a district hospital with hypoxia.  The team there had started treating him with a beta blocker and Lasix but he was not improving.  His oxygen saturation was 76% on RA and 90 on a NRB.  His HR was in the 60's ( B-blocked), and he was midly hypotensive with SBP in the 90's.  His chest xray was clear without pneumonia or pulmonary edema.  Given his Hypoxia, the resident suggested we perform a point of care Ultrasound ( I was so happy he initiated this Ultrasound ).  A formal ultrasound could take up to 2 days to obtain, and with the rate of patient turn over at this hospital, who knows if patient would last that long.  His Bedside Cardiac Ultrasound showed  a severely dilated RV and a large dilated non-collapsing IVC ( sorry the other videos won't download, so only one cardiac view).  We of course suspected a pulmonary embolism in this patient.  We performed bilateral point of care 2 zone DVT studies which were negative.  Emergency team decided to heparinize this pt given these findings.  This week I checked on him and he was off oxygen and sitting up breathing comfortably waiting for a bed on the medical service.  Never got CT PE...family could not afford to pay ( you pay for everything at this hospital...including the gloves that clinicians use to care for the pt).  No money, insurance = limited care. 

Case 2:  Young male in his 20s who had a motorcycle accident presented from District hospital with minor pelvic fracture.  It took him about 2 days from his trauma before he presented to our referral hospital.  He complained of severe abdominal pain with us.  He was scheduled for a CT scan of his abdomen but it was taking a while.  We performed  FAST ( Focused Assessment with Sonography for Trauma) on him and saw this.  Yeah....That's a ruptured bladder.  He got antibiotics and a Urology consult. They requested a CT scan which happened 2 days later and confirmed a bladder rupture.  He was then discharged with antibiotics, a foley and was scheduled for outpatient cystogram...This basically motivated the residents to do FAST's on all traumas even if transferred 3 days after injury!!!!!  This helps form habit....and the residents get to perfect their Ultrasound skills.  







Case 3

This is a necrotic leg...This woman's leg has been like this for a few months...why did she not appear that ill???...Well Doppler U/s of the vessels of her legs showed a femoral arterial clot but also incidentally bilateral DVT's which probably prevented severe systemic illness.  She had bilateral DVT's due to large pelvic mass. She ended up having her leg amputated and last time I checked she was doing well on the surgical service.  Unclear what work up she would have for her pelvic mass.    

Soooo Much Pathology here...Because CHUK is the referral center in Rwanda and has the only public CT scanner ( other one is at a private hospital and you need lots of dinero), we get everything at this hospital.  On any given day we have many positive FAST's, large pericardial effusions, and cardiomyopathies.  Great learning cases!!  These were just a few. Thanks for Reading

~Phindile Erika Chowa MD

Emergency Medicine Residency, MGH/BWH, PGY3 ?

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Point-of-Care Ultrasound Training for Emergency Medicine Residents in Kigali Rwanda

October 30, 2014

I am so grateful to have had the opportunity to join the PURE Team here in Rwanda and thank the Center of Expertise in Global and Humanitarian Health for making it happen.  PURE stands for Point-of -Care Ultrasound in Resource limited Environments and was created by a rock star former Harvard Emergency Medicine resident Dr. Henwood.  When Dr. Henwood gave a presentation on the impact of Ultrasound in resource limited settings her senior year, I knew that I wanted to not only perfect my ultrasound skills, but to also provide a useful skill to the practitioner abroad who sometimes may feel helpless when CT or Xray is not readily available.

Day 1
I survived a long trip to Kigali, Rwanda.  The view from the plane was amazing.  The landscape reminded me of my days as a child living in Swaziland.  I was picked up from the airport by one of the team members and given a short tour of the city before going home and crashing.  The people were wonderful and I even learnt a few greetings in the local language.

Day 2  We packed up the rental car to go to a district hospital about 2.5 hours away to give a training on Cardiac ultrasounds, FAST, and DVT ultrasound.  We drove up a windy road on a mountain ( mountains are very common here) where my heart literally wanted to jump out of my chest.  The view was amazing.

Unfortunately, the car broke down some where near the top of the mountain.  Within 30 minutes we had the local people call for the local mechanic.  The mechanic came on bike from Lord knows where and he diagnosed our car with an "engine problem" and called for the local tow truck to tow the car back to Kigali.

We paid about 300 US dollars to be taken back to Kigali Rwanda and to have the car towed-my pockets hurt still. It ended up being quite the experience, but somehow we had a wonderful day.  We met new people, saw a new place and broke bread together in the car.

After working in a few places in Sub-Saharan Africa one must be super flexible and adaptable, things happen and you must make the most of it.  I honestly had no complaints about this day.

Day 3
Okay finally work!!  We arrived at the University teaching hospital of Kigali at 8 am.  Our work is performed in the emergency and accident ward mostly, but other internal medicine, surgical and pediatric wards have requested to have scanning sessions for their residents.

 This ward serves a slightly different purpose than the emergency room in the US.  Most patients present from referring district hospitals and this can even be a matter of several days before arriving here.  I was told the role of the ED, is changing though with new emergency residents training in the hospital.  Our job is to teach and help facilitate scans with them and internal medicine, and surgical residents.  We in no way are here to take any role in patient care.

This day was busy, but apparently it gets more busy than this.  We had a number of scans in the morning. For example, we performed an ultrasound on pt who had known cardiomyopathy who presented to the hospital with shortness of breath.

The staff only had an xray from 1 month ago that they continued to refer to the size of the pt's heart.  For whatever reason, xray could not be performed that day.  We had the residents grab the US machine and look at the pt's lungs and heart.  He had bilateral pleural effusions, and diffuse B-lines likely representing interstitial edema.  His heart was globally dilated and had extremely reduced function.  The residents performed the scans and proceeded to treat the pt for a CHF exacerbation.

 We also had a trauma come in from the scene with GCS of 3.  One of the stellar training Emergency residents, ran the trauma.  A-B-C's initiated.  Pt airway was secured with ETT, He had a flail chest and decreased Breath sounds on the right and had a chest tube placed, and he was hypotensive and bradycardic.  His Pelvis was unstable.  The Emergency resident immediately called out for the US.  This was not typical in the past as part of the initial trauma evaluation, but the residents who are so excited about ultrasound have been incorporating it in most trauma pt's.  The FAST was positive excellent...now lets go to the OR??  or not...pt pressures were still in the 60s even with resuscitation. Blood was not readily available. Typically this would result in immediate OR intervention in the US, but the team felt that his head injury was too severe, and his quality of life would have been poor...watching resuscitation efforts/interventions stopped in this pt was a bit unsettling.

 I have been trying to understand the scenario from the Rwandan physicians point of view.  A part of me understands, but still a very difficult pill to swallow.

Until next time...      

~Phindile Erika Chowa,MD
 PGY 3
Emergency Medicine Resident, BWH/MGH

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Field work in Rwanda, February 2010

Christine Pace
Medicine PGY-3, BWH
April, 2010

With the support of the Center of Excellence in Global Health, I traveled to Rwanda for the month of February, 2010, to work with Partners in Health (PIH) at two of the rural district hospital sites where they work. This was my second trip to Rwanda, where I have been involved in helping develop mental health programming at PIH�s three sites. In the wake of the 1994-1995 genocide, mental illness, including depression and PTDS, is a significant public health problem in Rwanda. The Ministry of Health recognized this early on, and has tried to staff all district hospitals with psychologists and mental health nurses to address the significant need all around the country. In its mental health work, PIH aims to support existing Ministry of Health mental health programs and is also in the early stages of collaboration with MOH to pilot new programs.


During my first trip to Rwanda I conducted an informal needs assessment of the mental health services available at the three sites PIH works. I also developed training materials to help acquaint health care providers working in medicine, surgery and obstetrics with basic principles of psychiatric illness, and developed clinical protocols to help medical doctors and nurses distinguish between medical and psychiatric causes of psychiatric symptoms, such as psychosis. This year, I continued work on these protocols and conducted some pre-testing of them in the wards. In addition, with Ildephonse Fayida, a Rwandan psychologist who direct�s PIH-Rwanda mental health program, and Giuseppe Raviola, a psychiatrist at Children�s Hospital and PIH, I began to develop protocols for management of the most common psychiatric conditions encountered in Rwanda. As I did last year, I also had the opportunity to round on the medical wards with Rwandan physicians.

I have learned a tremendous amount from this experience. Clinically, I always both enjoy and deeply value the chance to round in the medicine wards, to work through difficult cases with the Rwandan doctors, and to learn from their experience. Obviously, the majority of the diseases we encounter there, such as malaria and typhoid, are seldom seen at BWH. However, as Rwanda develops its ability to diagnose and treat chronic diseases such as heart failure and diabetes, there are indeed overlaps with the diseases we see most commonly here�as well, of course, as fascinating contrasts between the epidemiology and presentations of such conditions in the two settings. It has been fascinating to work with Ildephonse Fayida, and learn more from him about the epidemiology and clinical manifestations of mental illness in Rwanda. In particular he helped me think about the ways that culture affects these manifestations. Culture differences aside, I valued the chance to review basic psychiatric disorders and their treatment; we have few opportunities to formally review psychiatry in our internal medicine training, and yet we work with patients who have psychiatric comorbidities all the time, particularly in primary care. Thus, having had the opportunity to develop clinical protocols in Rwanda will actually benefit my clinical practice back in the States as well. Finally, working alongside PIH staff on some programmatic issues allowed me the chance to better understand the ways that the program interfaces with the Rwandan Ministry of Health, and better appreciate the importance of such collaboration in global health. I had a wonderful experience in Rwanda and greatly appreciate the COE�s generosity in making my trip possible.

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