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Ultrasound Chronicles: Mass Casualty Case

1/14/2019

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"Within one day, I’d seen the training and careful preparation in the morning and practical application of the same knowledge in the afternoon.
​A great day of Global Emergency Care at work."
By: Dr. Michael Schick, GEC Ultrasound Director

As a second year Emergency Care Practitioner (ECP), Friday mornings are spent learning through simulation. On my recent trip to Uganda one of the morning simulations was a mass casualty event. In the simulation, a pregnant mother with her two children were riding on a boda when it crashed. Four patients, two with life threatening emergencies and two who were injured but less severely. The ECP running the case is tasked with rapidly assessing each patient, triaging them, quickly deciding who needs immediate intervention and assigning tasks to other ECPs. Each ECP is assigned to one of the patients with priorities set.

It was a fun and engaging morning of learning and I was impressed with the skills demonstrated and questions generated by the ECPs. We discussed prior mass casualty events that have come through the ED at Masaka and how the ECPs divided tasks during those events. With road traffic accidents being so common and so deadly in Uganda, this is something the ECPs had witnessed many times. Entire buses that have rolled over, two bodas with several passengers each colliding, open trucks with several people in the back that veered off the road. Each event is challenging, intellectually and emotionally, and the ECPs shared what they had learned from these events.


That afternoon, we joined the other ECP trainers in the emergency department seeing patients. The ED was busy that afternoon and the ECPs were busing seeing several patients; one with a piece of wood stuck in the bottom of the foot, another with a large laceration of the hand, a patient with pneumonia, another with abdominal pain, another with malaria. A truck pulled up outside and Alfunsi went to assess the situation. When came back in, he announced that we had a mass casualty. The truck was loaded up with several injured men, all from the same accident, some walking, some unable to walk. A truck had rolled over on the road outside of town. We were about to do what they’d just trained for.

The ECPs began putting on personal protective equipment (gloves and gowns) and taking stretchers outside and making space in the crowded department. Alfunsi assumed the role of leader, directing the others who were doing primary and secondary surveys of each patient. One of the ECPs went bed by bed with the ultrasound machine doing EFAST exams.

Having working in U.S. EDs and witnessed similar large scale trauma events over many years, I must say, the ease and rapidity with which the ECPs assessed and managed these patients was SMOOTH. What can seem like chaos for someone watching for the first time, is in fact well-orchestrated prioritization through systematic evaluation and when done right, it is a beautiful thing. When done poorly, patients can die. A true emergency provider looks past screaming and blood and fearful patients to see the problems that need an immediate intervention: abnormal vital signs, a positive FAST, or pneumothorax. This is the difference between good training and poor preparation. The ECPs were completely unfazed. Alfunsi had prioritized two of the patients as critical within five minutes. The ECPs managed each injury from large to small. One was sent to the OR and another needed transfer for a spinal fracture. The remaining patients were lower acuity and though some would be admitted, there were no further critical procedures needed.

Within one day, I’d seen the training and careful preparation in the morning and practical application of the same knowledge in the afternoon. A great day of Global Emergency Care at work.
Ultrasound Machine Fundraiser for GEC - 100% Match
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. 
Double Your Impact Today!
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Ultrasound Chronicles: Umbilical Hernia

1/8/2019

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"As our primary diagnostic tool, ultrasound can provide a fabulous amount of confirmatory and ancillary information."
By: Dr. Michael Schick, Director of Ultrasound

While working in the emergency department at Nyakibale Hospital in Rukingiri, Uganda a two-year-old boy arrives with his mother for persistent vomiting. He appears ill, has an elevated heart rate, but no obvious fever. Gastrointestinal illnesses are extremely common in this region of the world and account for a large proportion of childhood deaths, related to dehydration.

While most children presenting with vomiting, will also have diarrhea from either invasive of non-invasive intestinal infections this child was not suffering from diarrhea. Vomiting in isolation in a young child can indicate a benign illness like common childhood viruses, food toxicity, but can often indicate life threatening intra-abdominal emergencies or intra-cranial emergencies such as meningitis.

The child was listless, tired and not fighting against our Emergency Care Practitioners (as many toddlers normally do); he was dehydrated, but other than that the patient had no signs of meningitis. As we undressed the child, our astute Emergency Care Practitioner found the patient’s abdomen to be distended, tympanic, and with an obvious umbilical hernia. If you have never seen an umbilical hernia, it is a large protrusion from the belly button.

​One risk of any hernia is that bowel or intestine can get stuck inside it and twist, which cuts off blood flow to the intestine. Like all things, without blood flow the intestine will die. Bowel will become obstructed, necrotic, and release stool contents inside the abdomen. Life threatening infection ensues and in this region, certainly death.

As our primary diagnostic tool, ultrasound can provide a fabulous amount of confirmatory and ancillary information. We first image the four quadrants of the abdomen, which in the upper abdomen demonstrates large, dilated loops of bowel with anterograde and retrograde peristalsis. This indicated the patient has a bowel obstruction.
In the lower abdomen, his bowel appears normal, which indicates the obstruction is higher than the bowel imaged. When we place the probe on the umbilicus we see intestine within it and adjacent free fluid. We have difficulty acquiring reliable color flow from the intestine.

We consult surgery immediately and t
he patient is taken to the operating theater. The surgeon successfully released the strangulated umbilical hernia. Even though we had feared intestinal necrosis and perforation, the surgeon found the bowel to be well perfused. The patient had an uneventful post-surgical course.
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.
Donate & Double Your Impact
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Ultrasound Chronicles: RUPTURED ECTOPIC PREGNANCY

12/6/2018

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By: Lori Stolz, MD, GEC Ultrasound Director & Alexa Sabedra, MD, GEC Volunteer
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On our first day in Masaka, while sitting in on the chest pain lecture being given to the ECP 1s, Deus (an ECP 2 who was working in the ED at the time) quietly walked in and asked if Dr. Lori could bring the ultrasound to the ED.  On the way there he explained that a young woman in her early 20s had presented to the ED complaining of bloody stools and had low blood pressure. She had been seen by one of the intern physicians who was also working that day. The doctor thought that she had bleeding inside her intestines and was planning to admit her to the ward.  Deus heard about the patient and had noted that she had a positive pregnancy test. Knowing this information, he was concerned that something more was going on.


On arrival at the bedside the team found an unwell appearing young woman. She was pale, another ECP was repeating a blood pressure and having trouble getting a reading.  Deus wanted to perform an ultrasound exam to look for internal bleeding, a FAST exam. In a pregnant patient who is having abdominal pain or vaginal bleeding, a ruptured ectopic pregnancy could be the cause.  An ectopic pregnancy is when a pregnancy implants outside of the uterus, usually in the tubes. This is a life-threatening condition which is the leading cause of death in women in the first trimester worldwide.
Deus started the exam with a view in the right upper quadrant of the abdomen that looks at the liver and kidney.  Almost immediately, he spotted the black stripe between those 2 organs and correctly interpreted this as free fluid (Blood!).  Already the team could tell that Deus had been right; that this was more than what it seemed. He next moved the ultrasound probe to her lower abdomen to look in the pelvis.  He was able to see the woman’s uterus which was empty. This is not the expected finding if it was a normal pregnancy. He moved the probe a little to the left and was able to see a gestational sac (the pregnancy)…but the sac was outside the uterus!!  There was more of the black free fluid in the pelvis as well. Now there was no question. This woman did indeed have a ruptured ectopic pregnancy that was the actual source of her bleeding and low blood pressure. This woman did not need to be admitted to the ward, and in fact would have likely died there had Deus not intervened.  The woman needed to go to the operating room right away. Deus knew this and called the surgeon who did just that.
We later learned that in the OR the surgeon confirmed the left sided ectopic pregnancy and bleeding.  They were able to remove the ectopic pregnancy and stop the bleeding. The woman lived and the next day was doing very well.  A life was saved thanks to the quick thinking of the ECP and his skillful application of ultrasound to confirm the diagnosis he suspected.
​

I think this case is very special.  As someone new to volunteering with GEC it really highlighted what an incredible resource the ECPs are for Uganda.  It is amazing how much they have learned from their training and how well they apply it to patient care to save lives!  In this case, the ECP was better able to evaluate the patient than even the physician. What is troubling is that the ultrasound machine that was here at Masaka is currently broken.  The cost of fixing it is nearly that of a new machine. When Dr. Lori and I came, we were lucky to have the generous support of organizations back home that allowed us to borrow a few machines to teach the ECPs while we are here, but they are sadly coming back to the U.S. with us.  While we are here, we have been working on ways to obtain a new ultrasound machine for the ECPs. Please help us reach that goal with a donation. ​
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.
Donate Today
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Breaking barriers in emergency medicine education

11/21/2018

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Our team was thrilled to participate in the 4th African Conference on Emergency Medicine this month in Kigali, Rwanda. Thanks to the conference’s close proximity to Uganda, 18 GEC team members were able to attend the three-day event, from Emergency Care Practitioners, researchers and students, in addition to U.S.-based board members, staff, and volunteers. 

Nyakibale Research Coordinator, Adrine Kusasira, and Research Associate, Charles Ndyamwijuka, did an excellent job in their first presentation. They worked with GEC volunteer, Ashley Pickering, to present on factors contributing to delays in emergency medical care at Nyakibale Hospital in rural Uganda.

GEC board member, Mark Bisanzo, presented on management of acute heart failure in low-resource settings, while Stacey Chamberlain, also a board member, presented on global partnerships in emergency care. GEC volunteer, Greg Gaskin, presented his paper on Information Technology Supporting Emergency Care in Sub-Saharan Africa: A Scoping Review and Commentary.

Our team also participated in a full day stakeholder meeting with the Emergency Medicine Uganda community. It’s an exciting time for emergency medicine in Uganda as partners continue to develop relationships and build coalitions that drive the growth of emergency medicine by Ugandans for Ugandans.

We’re newly energized from learning about other innovative programs and models in emergency medicine across Africa. The GEC team returned to Uganda excited to implement new ideas, foster relationships with new friends, all the while working hard to move emergency medicine development forward across Uganda.

GEC Presentations

  • Building It so They Will Come: Factors Contributing to Delays in Seeking Available Emergency Medical Care in Rural Uganda and Surrounding Countries
    • A Systematic Literature Review
      Ashley Pickering, GEC Volunteer
    • ED Patient Case Studies
      Kusasira Adrine, Nyakibale Research Coordinator
    • Community Focus Groups
      Ndyamwijuka Charles, Nyakibale Research Associate

  • Global Partnerships in Emergency Care
    Stacey Chamberlain, GEC Co-founder and Development Director

  • Management of Acute Heart Failure in low Resource Settings
    Mark Bisanzo, GEC Co-founder and Director of Programs

  • Information Technology Supporting Emergency Care in Sub-Saharan Africa: A Scoping Review and Commentary
    Greg Gaskin, GEC Volunteer

  • Derivation and Validation of a Chief Complaint Shortlist for Unscheduled Acute and Emergency Care in Uganda
    Brian Rice, GEC Research Director

  • Sepsis Outcomes in a Ugandan ED Staffed by Non-physician Clinicians
    Sal Calo, GEC Volunteer
Please consider a donation today. Your gift will ensure that more GEC's Ugandan team will have future opportunities to attend conferences and other professional development opportunities. Thank you!
Donate Today
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First-Ever ECP Diploma class

12/6/2017

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By: Dr. Stacey Chamberlain, Development Director, Co-Founder

​It is so exciting to announce that in September 2017 GEC finally started the first class of Emergency Care Practitioners that will receive Diplomas upon completion of their training program from our partner university, Mbarara University of Science and Technology (MUST)! This is a landmark accomplishment that will greatly improve the sustainability of our programming as it truly integrates our training program into the local educational system. 
 
Imagine if you went to nursing or medical school, and at the end, you didn’t receive an actual diploma and a nationally recognized degree. You wouldn’t be able to use your life saving clinical skills because employers would not recognize your expertise without that piece of paper. So after many years of fine-tuning our curriculum and working with our Ugandan partners including Masaka Regional Referral Hospital, MUST, and the Uganda Ministry of Health, this roll-out is a big step in the creation of a workforce of Ugandan emergency practitioners that will have the skills to treat acutely sick and injured patients. 

We are thrilled to welcome our first class of Emergency Care Practitioner Diploma trainees: 
Joyce Nakajja
Winifred Auma
Mohammad Kyambadde 
Edward Kasiira
Henry Kagaba
Harriet Ijangolet
Jane Frances Birungi 
John Twesigye
​
TO RECRUIT & TRAIN THE 2018 CLASS OF ECP DIPLOMA STUDENTS, WE NEED YOUR SUPPORT

Now more than ever, your gift will make a huge impact. It allows us to train even more Emergency Care Practitioners who transform health outcomes and save lives in some of Uganda’s most underserved communities.
Donate Today
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Emergency care & the sustainable development goals

6/2/2016

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Emergency care has the potential to be a major driver towards successful completion of 10 health-related Sustainable Development Goals (SDGs) targets. The SDGs are a new, universal set of goals, targets, and indicators that UN member states are expected to use to frame their agendas and political policies over the next 15 years. The SDGs follow and expand on the millennium development goals (MDGs), which were agreed by governments in 2001 and expired at the end of 2015.
 
As an NGO working in global health and development, GECC strongly supports the SDGs and works to help reach the identified targets by 2030. In fact, GECC is in a unique position to contribute to SDG success because our mission to increase access to emergency care can directly improve outcomes for 10 different SDG targets.

Those targets are:

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  • By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
  • By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
  • By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases (NTDs) and combat hepatitis, water-borne diseases and other communicable diseases
  • By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being
  • Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
  • By 2020, halve the number of global deaths and injuries from road traffic accidents
  • Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
  • By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination
  • By 2030, significantly reduce the number of deaths and the number of people affected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations
  • Significantly reduce all forms of violence and related death rates everywhere
 
Training Emergency Care Practitioners to diagnose and treat acutely ill and injured patients is a horizontal intervention that cuts across many disease-based interventions, like HIV/AIDS, TB, malaria, and NTDs, as well as a wide variety of other public health interventions, like infant and maternal mortality, injuries, road traffic accidents, substance abuse, poisonings, water borne diseases, disasters, and violence. Because emergency care clinicians usually are the first to treats patients with a wide variety of diseases and injuries, the proliferation of specialty trained emergency care clinicians will not only provide essential surveillance, but also improve outcomes in no less than 10 SDG target areas.

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Emergency Care Comes to masaka

5/24/2016

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"I am incredibly thankful. Not only because I have GECC trained providers in my area to save lives and manage other emergencies, but also because I am part of the organization that’s working hard to make it happen."

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By: Rashidah Nambaziira, GECC Program Coordinator - Masaka

Every once in a while something happens that reminds me of why the work GECC is doing is invaluable, and worth the effort we all put in. GECC has been training nurses to deliver emergency care since 2008 in Nyakibale, Rukungiri, and has recently started a similar program in Masaka. Masaka Hospital presents a whole new set of challenges because it’s a public hospital: there are more patients who are sicker, and the resources are limited to what the government provides as part of free health care to the public.
 
Four of GECC’s qualified Emergency Care Practitioners (ECPs) have been training the nurses that work in the Emergency Department (ED) at Masaka Hospital for the past 6 months. In this short time, the progress is very evident in both the patient outcomes and the changes in ED patient management.  It’s even more evident in the stories the ECPs, the GECC research team, and the ED nurses tell about the impact of the training on management of individual patients. This story is an example of that impact. 
 
While working in my office, which is in the same building as the ED, I heard a loud cry from the ED; this is not unusual since we get a lot of patients screaming from pain. I went in anyway, because the crying seemed to increase with more people joining in. It was an older woman screaming in pain with a large laceration on her scalp, a bleeding cut above her right eye, and bleeding from the mouth with fractured teeth; she was covered in blood! She had been brought in by her 40-year-old son and her 37-year-old daughter, who explained between cries that her name was Joyce and she had been knocked down by a bodaboda (motorcycle taxi) on her way from visiting a friend across the street a few minutes ago.
 
 Alfunsi, our qualified ECP, triaged the patient as needing immediate care above all the other patients waiting in the ED. He asked for the nurse on duty, who also happened to be a student of the GECC Emergency Course, to get vitals on the patient, as he started assessing the ABCs and other trauma survey.

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The patient was in shock from losing so much blood. Her vitals were barely recordable and her O2 saturation was 80%. Harriet, the student, quickly ran to connect oxygen, but the tank was empty! This is not unusual in a public hospital, so as usual, she had to run to other wards to try and borrow an oxygen concentrator.  In the meantime, Alfunsi tried a jaw thrust and later an airway piece to try and clear the airway, which worked for a while as we waited for Harriet to get oxygen and allow Alfunsi to stop the bleeding on the head from causing more blood loss. Teddy, another ECP joined in to replace Harriet. She started two IV lines for fluid resuscitation, and sent some blood to the lab to get blood for the patient. Thankfully, Harriet managed to track down a driver to help borrow an oxygen concentrator from a private ward; oxygen was connected, the vitals were not great but good, and a patient monitor was connected to keep the vitals in check. Teddy got blood from the lab, connected it, ran more IV fluids, and then returned to other sick patients in the department. The patient was stable, and Alfunsi was suturing and cleaning the other multiple wounds.
 
A few minutes later, the patient’s condition deteriorated, the vitals went haywire, she started gasping for air, aspirated, and stopped breathing. At this point, the daughter thought her mother had breathed her last, so she broke down, started screaming and calling the relatives in the waiting area, who all rushed into the procedure room to come say bye to their mother.  With the limited number of staff, and other patients in the ED, I had to join the team.  I ran to get the suction machine for Harriet to start suction, then I talked to the relatives to calm down and wait outside and that the team was doing their best to try and save their mother.  Alfunsi and Harriet bagged the patient and then started CPR. The patient was brought back, and within a short time, she was stable, blood and fluids running, antibiotics started, wounds cleaned and dressed, and the patient was ready to go to the ward for further monitoring that evening.

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Everyone in the ED that day, including the relatives could not believe that the woman survived. They all were amazed at the efficiency, skill, and dedication of the team that worked to save the patient. I kept thinking about what would have happened if we didn’t have 1) trained ECPs with the skill to assess and manage trauma (suture, clear the airway as we waited for O2, and to do CPR); 2) the equipment to check and monitor vitals to recognize shock and an O2 saturation of 80; and 3) a well-trained team of people that understand triage, jump in when priority of one patient arises, but also keep the management of other patients in the ED going regardless of staff shortage.  
 
Thankfully, for this patient, all these were available, because of the Emergency Course that GECC started at Masaka Hospital. Without intervention of a hospital doctor, ECPs and their student managed this case, and have managed numerous similar cases since their arrival at Masaka six months ago. If we had come this far in three months, I can only imagine the level of Emergency Care after years of this training.  While I talked to Joyce’s son on the phone yesterday, and as he told me how she is doing at home, and how grateful they are for effort our team put in, I am incredibly thankful; not only because I have GECC trained providers in my area to save lives like Joyce’s and manage other emergencies, but also because I am part of the organization that’s working hard to make it happen. 

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Copyright 2015-2019. All Rights Reserved. P.O Box 4404 Shrewsbury, MA 01545. GEC is a 501(c)3 non-profit organization. All donations are tax-deductible. Thank you for your support and generosity.