Ultrasound Training Update
As part of our ECU ultrasound training curriculum, we conducted our second, third, and fourth ultrasound courses in late February and early March. As presented in a previous blog post, our first ultrasound course covered comprehensive echocardiography (ECHO). The first course's participants included Burmese radiologists and senior medicine physicians without formal ECHO training, although the radiologists are experts in most other ultrasound exams. The course also incorporated components of a training of the trainer (TOT) curriculum to help prepare the radiologists to teach future ultrasound courses to the MTC medics in the Burmese language. As part of our MTC ultrasound curriculum development, I created a series of ultrasound lectures covering the most critical aspects of emergency ultrasound, including ECHO, IVC assessment, eFAST, lung, and RUSH exams. In preparation for our future US courses, these lectures were reviewed and edited by the two Burmese radiologists currently at MTC who had taken the comprehensive ECHO course.
In February, I conducted an ultrasound workshop for a group of final-year medical students from Myanmar who had had their medical training interrupted by the military coup as they joined the civil disobedience movement. After some of them spent time providing medical care to resistance fighters, they now work as clinical officers at MTC. The workshop was held in English as they all have excellent English language skills. The course was an opportunity to advance their knowledge and skills, as this was the first time the students had had exposure to ultrasound training. The workshop was three days long and covered basic ECHO with IVC assessment, eFAST exam, and lung ultrasound. Each day, we reviewed one of the topics, spending the mornings in interactive lectures and the afternoons practicing hands-on ultrasound skills in the MTC IPD.
In addition to the student ultrasound workshop, we held two ultrasound courses for MTC medics: one for junior medics and a separate course for senior medics. The Junior medic ultrasound course covered the basics of ultrasonography, eFAST, lung, and IVC assessment. The senior medic course covered the junior medic topics of eFAST, lung, and IVC assessment, plus the additional topics of basic ECHO and the RUSH exam. My Burmese radiologist colleagues did an incredible job facilitating the course, and unsurprisingly, given their extensive previous skill in non-ECHO ultrasound and the numerous patients with abnormal ECHO findings at MTC, they have become proficient in ECHO in the short time since participating in the ECHO course. Beyond the radiologists becoming skilled echo-sonographers, by the end of our course, all 9 of the senior medic participants successfully performed an ECHO, obtaining the four main views: parasternal long axis, parasternal short axis, apical 4-chamber, and subxiphoid, plus an IVC assessment. They also successfully analyzed the ECHO images they obtained reporting on the five E's of ECHO, which include...
Effusion (does the patient have a pericardial effusion)
Ejection (evaluation of left ventricular function, aka ejection fraction)
Equality (evaluation of right heart strain, normal ratio of right:left ventricles is 0.6:1)
Exit (diameter of the aortic root)
Entrance (evaluation of inferior vena cava (IVC) diameter and collapsibility)
Below is a video of a lecture by Dr. Heidi Kimberly (presenting at the Downeast Emergency Medicine winter symposium in Maine) reviewing the 5 E's of Echo if you would like to learn more about the material we are teaching. As part of our overall project we will be recording our Burmese language ultrasound lectures as part an Myanmar border emergency medicine educational hub that we are developing.
Given the extensive pathology seen at MTC, during the hands-on skills portion of the courses, we uncovered multiple abnormal ECHO findings, including heart failure with reduced ejection fraction, right heart strain, pericardial effusion, tricuspid valve vegetations, mitral valve prolapse, and dilated cardiomyopathy. These findings again highlight the critical importance of increasing MTC's capacity to perform ECHOs both in the future ECU and in the IPD.
ECHO Performed by Medic During Ultrasound Course
One patient with a particularly interesting ECHO was a 49 yo M who presented with worsening abdominal distension, lower extremity edema (swelling), decreased appetite, and generalized fatigue. He denied shortness of breath and had no history of liver pathology, kidney disease or previous ECHO performed.
The following ECHO shows significant right heart strain with severely dilated right atrium, severe tricuspid regurgitation, mild mitral regurgitation, pericardial effusion, and a plethoric IVC. This ECHO is consistent with the patients clinical exam findings of right heart failure. What is not clear is exactly what is driving his extensive right heart failure and dilation. The differential diagnosis for such findings include rheumatic heart disease affecting the tricuspid valve leading, congenital heart abnormalities such as Ebstein's anomaly which can have variable morphology, and atrial septal defect. Pulmonary hypertension is another cause of chronic right heart strain, however, this patient does not have clinical symptoms consistent with pulmonary hypertension such as shortness of breath. Pulmonary embolisms (blood clots in the lung vasculature) are often a cause of acute right heart strain, however, this patient's ECHO findings and clinical presentation are more consistent with chronic right heart strain and are not consistent with pulmonary embolism. The patient is experiencing improvement in symptoms with diureses from furosemide. We are working to arrange evaluation by a cardiologist and including a comprehensive ECHO to help determine the exact etiology of his right heart strain.
Parasternal long axis showing enlarged right ventricle and pericardial effusion
Parasternal short axis showing right heart strain and pericardial effusion
Apical 4-chamber showing right heart strain with severely dilated right atrium
Apical 4-chamber showing right heart strain with severely dilated right atrium, with color doppler showing severe tricuspid regurgitation
Plethoric IVC indicating elevated central venous pressure as a result of the patient's right heart strain
Emergency Care Protocols
We continue to meet regularly with our emergency care protocol working group. Recently Dr. Tiah Ling, an emergency medicine physician from Singapore, returned to MTC and she will be here for several months. She is leading our clinical protocol development and the first draft of our anaphylaxis protocol has been created. Our protocol development is time consuming as we are trying to follow international best practice standards while adjusting protocols to our unique context and to fit the resources available at MTC. We are combing previous MTC protocols, the Burma Border Guidelines, WHO recommendations, and national/international medical society guidelines. We will continue to review our guidelines and ultimately they will be approved by our protocol working group, ECU consulting team, MTC clinical leadership, and MTC administration prior to putting them into practice. Once complete these protocols will be shared and open access should other healthcare facilities with similar resources as MTC wish to use them as a template for their own protocols. Stay tuned as I will share an example of our emergency care protocols in the next blog post.
New Prosthetic Workshop at MTC
Following the successful prosthetics training course that I wrote about in a previous post, MTC has begun construction on a new prosthetic fitting and manufacturing workshop (pictured below). It is unfortunate that MTC needs to re-open their prosthetic clinic due to the rise in people requiring amputations from traumatic injuries sustained while fighting for freedom and democracy since the 2021 military coup. However, this is a critical project that will provide hope and a future for countless people, many of them young.
The main road into the clinic is being expanded and repaved so for a short time we are arriving via a dirt access road, below is a short video of the current ride into the clinic.
Finally, here are a few photos of flowers that I took around the clinic to share with my grandma while she is enduring a cold Canadian winter where she lives in North Bay, Ontario.
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