At Masaka Hospital in Uganda our Emergency Care Practitioners (ECPs) have acquired specialized emergency training in point-of-care ultrasound. In this specific diagnostic skill set, they are the most trained practitioners in the region. While teaching our ECPs ultrasound we often take to the medical wards, where pathology is plentiful. There we also interact with the ward medical/surgical teams, and often our “practice” scans drastically change management.
When we arrived on the medical ward we immediately find a young man tripodding on his hospital bed. If you have never seen a person tripod, it is alarming. It means they have their arms in front of them, supporting their body as they sit, struggling to breathe. In a healthcare setting that has no intensive care units or advanced airway interventions, this is a frightening presentation.
The medical doctor tells us he is being treated for heart failure and pulls out a single view AP chest x-ray. Indeed, his cardiac silhouette, or the size of his apparent heart is large which is one of the signs we look for to indicate heart failure. But, I don’t see much fluid in his lungs, which is what you would expect in a typically heart failure exacerbation. Also, this is a young man, why does he have heart failure? It is usually a disease of the elderly. We considered a congenital heart defect as the cause, but still, it was a bit perplexing.
I discuss with our ECPs that fluid around the heart or a pericardial effusion will also give you an enlarged cardiac silhouette on chest x-ray and, in this setting, cardiac tamponade from an infectious disease, such as tuberculosis or pericarditis, is a critical distinction. It is critical because the treatments are completely different. Cardiac tamponade requires drainage of the fluid around the heart with a needle and treatment of the underlying condition whereas heart failure is often treated with medications that reduce stress on the heart and remove fluid from the body. Cardiac tamponade and pericardial effusions are diagnosed primarily with ultrasound.
When we place the probe on the patient’s chest it is immediately clear he has a large, complex appearing pericardial fluid collection. He is indeed in cardiac tamponade, where the fluid around the heart is crushing the heart itself until it cannot function. He did not have heart failure and the treatment he was receiving had made him worse. He is near the brink of death. One of our ECPs assists with the ultrasound while one of the surgery medical officers drained the patient’s fluid at the bedside. The fluid removed was thick and concerning for a infection in the fluid.
In the United States, he would likely have gone to the operation room with a cardiothoracic surgeon and had his pericardium completely removed. Those resources are not available in Masaka. Though we were able to make the correct diagnosis and drain the fluid, the following day the patient died. He had likely died from sepsis associated with the infected fluid. If ultrasound becomes more widely available and training is more widely available, I believe young men like this patient can be saved.
Ultrasound Machine Fundraiser for GEC
Thanks to a very generous gift from the Ellis family in honor of their parents, Dan and Barbara Ellis, we will be offering a 100% match on all ultrasound donations up to $10,000. Our goal in the next month is to raise $30,000 to fix one of our current ultrasound machines and to purchase two new ultrasound machines.