Educational course outreach in Saint Lucia quickly leads to life-saving procedure.
Introduction
Volcanic in origin, Saint Lucia is one of many small islands that comprise the Caribbean’s Windward chain. Renowned for its iconic twin peaks of Gros Piton and Petit Piton, Saint Lucia is a popular vacation destination. The International Emergency Medicine and Ultrasound Divisions at Stony Brook in New York were excited to work alongside emergency physicians on the island. We had an inside track as a senior EM resident is a Saint Lucian native.
Saint Lucia is a Caribbean Island that has a mixed history of colonization by both the French and British before ultimately achieving full independence in 1979. The island continues to recognize Queen Elizabeth II as the titular head of state and remains a member of the Commonwealth of Nations. The island cooperates with its neighbors through the Caribbean community and common market, the East Caribbean Common Market and the Organization of Eastern Caribbean States. Currently, the island population is just under 200,000 and English is the main language for the primarily Afro-Caribbean residents.
Victoria Hospital is the main public hospital of the island located in the capital city of Castries. Our contact there was Dr. Lisa Charles, the head of the Accident and Emergency Department who has worked as an emergency medicine attending at Victoria Hospital for over 15 years. Dr. Charles told us the A&E had one ultrasound machine for bedside imaging and the clinicians wanted to improve their skills to optimize this resource. The Ultrasound Division and Division of IEM crafted an educational course of mixed didactics and practicum scanning activities. Recognizing the resource constraints of this small developing island state, our team volunteered their time and enthusiasm. Eight of us shipped out, armed with lectures, portable ultrasound machines, a focused practical curriculum and our Saint Lucian EM resident!
Dr. Jonathan Kneib (second from right), International EM and Ultrasound Fellow, helps instruct on DVT scanning use at the bedside.
Something to Talk About
I found myself looking out at 30 unfamiliar faces anticipating a lung ultrasound lecture that provoked some conflicting emotions, but anxiety was currently winning. Not only was this my first presentation to an international audience, but it was also the first significant lecturing experience of my medical career. And I wasn’t certain anyone would be interested in listening.
The faces in the audience were skeptical. They were a mix of emergency physicians, intensivists, general and orthopedic surgeons, anesthesiologists, OB/GYNs and primary care physicians at Victoria Hospital. Victoria Hospital sees a high volume of trauma patients despite the seemingly relaxed Caribbean atmosphere. Of their 25,000 annual emergency department visits, 15 to 20 percent involve trauma. The hospital has an on-call overnight x-ray technician, and if a patient requires a CT scan they must pay out of pocket at the private hospital elsewhere on the island. The emergency department had an older-model SonoSite, which I was told had limited use.
I got through the first segment of my talk, discussing the “ants on a log,” the “sandy beach” and the “barcode sign,” along with other bedside ultrasound buzz words for lung sliding. To my surprise, the group appeared engaged, but I wasn’t convinced. At our home institution, we taught these topics to medical students and interns, and I didn’t think the material was very inspiring. But as we moved on from the rest of the didactic lectures of the day, the enthusiasm seemed to grow as we proceeded to the hands-on portion of our course.
Putting Lessons Into Practice
Our group of eight was pulled in multiple directions to the hospital’s wards, where Dr. Charles and her colleagues pre-selected and consented several patients for our hands-on bedside ultrasound practicum. Back home, our courses typically involve standardized patients with normal anatomy for practice. In contrast, we had the immediate advantage of scanning advanced pathology at the bedside. We imaged patients with loculated pleural and pericardial effusions, tense cirrhotic ascites, severely reduced ejection fractions and an upper extremity DVT that extended into the internal jugular vein.
My group stood around each bed pressed against one another in the hot, cramped rooms watching the ultrasound screen with fascination. The patients themselves asked many questions about their own pathology, which they were seeing for the first time. As each participant put their hands on the probe, the atmosphere blossomed with excited energy. Dr. Tylor Reynolds, the A&E senior house officer, was in my group and showed a particularly strong interest in lung anatomy. We attempted to model pneumothorax by having the patient hold her breath. My group would not quit until they fully understood the images of pleural sliding. My nervousness over the morning didactics became secondary: the physicians were captivated by the visual pathology they were seeing on their own patients.
Senior house officer Dr. Tylor Reynolds (second from left) observes a DVT scanning session on a ward patient. Reynolds would later use this knowledge to place a successful chest tube on her first overnight shift after the Stony Brook ultrasound course.
The next morning, Dr. Charles asked Dr. Reynolds, to recount an experience from her overnight shift after our first day of teaching. At 2 a.m., Dr. Reynolds received a quickly decompensating young male patient with multiple stab wounds to both sides of the chest. The X-ray technologist was out of the hospital and not readily available so Dr. Reynolds grabbed the bedside ultrasound, noted absent left lung sliding and immediately diagnosed a left-sided pneumothorax. The urgency of the patient’s condition mandated rapid intervention, and she was confident enough in her diagnostic imaging to place a chest tube on the correct side and save his life. Less than 12 hours from the ultrasound teaching, her new bedside scanning skills were used to save a life!
I stayed at Victoria Hospital for two more weeks, and saw enthusiasm for scanning and confidence in their skills spread throughout the Victoria Hospital medical staff. My initial fear was more than disproven when the director asked me to give the entire course again. In the few months since returning to Long Island, I have kept in touch with the physicians at Victoria Hospital. Many have relayed similar stories of their newfound ultrasound skills diagnosing life-threatening conditions in real time.
Lessons Learned
Why did our international ultrasound curriculum succeed? It involved a genuine understanding of our participants’ needs and practice patterns thanks to the local leader, Dr. Lisa Charles, who identified what would be best received. For example, we could have given a stock curriculum covering the six core ACEP applications: FAST, cardiac, biliary, aorta, renal and pelvic, but our audience had different needs. Our participants requested a focus on soft tissue and thoracic, as well as cardiac, biliary and pelvic to benefit our surgical, obstetric and primary care specialties.
Dr. Arie Francis, a Saint Lucian EM resident at Stony Brook University demonstrates vascular ultrasound in the classroom at Victoria Hospital.
While teaching abroad, it is also important to consider that your participants already have the clinical knowledge, skills and expertise to care for the most complicated ED patients. Many of our colleagues in Saint Lucia trained in Cuba or the University of the West Indies and most surpassed my years of experience practicing. It’s not the clinical acumen that they required, but the skills to use a simple, portable and inexpensive bedside tool to help diagnose and treat the sickest patients. We were all impressed by how quickly our participants developed proficient diagnostic scanning skills, as shown by Dr. Reynolds’s great save. Ultrasound has proven again to be an incredibly powerful resource in developing international settings.
Conclusion
You can’t “sell” this type of course to an under-resourced and generally under-paid group of physicians like the dedicated group in Saint Lucia. The money just isn’t there. If you want to bring it, however, they are eager to get involved. For us, teaching an accessible ultrasound curriculum was a perfect way to open a door to meet and collaborate with new colleagues.
This teaching experience was one of the most rewarding events of my EM career. I left Saint Lucia impressed by the local physicians and their dedication to caring for their home communities. Our bedside ultrasound course was successfully designed for a low resource environment and created a cultural bridge to a talented group of colleagues. We already have plans to go back!