Hot off the Press: Typhoid intestinal perforation: Point-of-care ultrasound as a diagnostic tool in a rural Ugandan Hospital
With its miniturization, affordability and broad utility, point-of-care ultrasound (POCUS) is a technology that is being seen increasingly not just in the emergency centers, but also as a front line diagnostic tool in the pre-hospital and field environments (1-4).
The African Journal of Emergency Medicine came out with a preliminary case study recently about a non-physician clinician living in Uganda (5). He had some training in POCUS and performed a focused assessment with sonography in trauma (FAST) exam on a child who had been recently treated for typoid and presented to him with moderate abdominal pain and tenderness with mild distension, but no peritoneal signs. The practitioner discovered a large quantity of complex fluid in the right and left upper quadrant. He had learned during his training that a large quantity of complex fluid may represent bowel contents, and he immediately contacted a surgeon who dropped everything to come to the hospital. The patient immediately underwent a laparotomy and it was found that he had two small perforations of the small bowel, later determined to be secondary to Salmonella typhi.
A training program has been put in place to train non-physician clinicians who live in resource-limited settings in the practice of point-of-care ultrasound. The curriculum is only 12 hours of didactics and hands-on training by visiting physicians from the U.S. It has previously been shown that a brief training period has proven adequate to allow pre-hospital providers to accurately assess trauma patients for internal injury (6,7). Given the minimal time requirements, having hands-on ultrasound experience appears ideal for wilderness medicine practitioners, as the new era of handheld ultrasound makes it an ideal technology to be able to strap in your pa ck. Having an ultrasound would allow you to assess for pulmonary edema in your evaluation of HAPE on a mountaineering expedition. It would allow you to assess for a fracture following a climber’s fall. It would allow you to assess for internal bleeding following a trauma.
The breadth of ultrasound’s potential is great, and new ways of using it to evaluate various pathologies are being documented constantly. In an area of low resources, whether it be in the middle of Uganda or on an expedition to Everest, having an ultrasound handy and being familiar with it would be an invaluable resource. As shown in this paper, sometimes it can mean the difference between life and death, whether it is to help you justify the emergency insertion of a needle for aspiration of a pneumothorax, or if it is just to give you support when imploring the gravity of a situation to a colleague.
- Wagner, M., Garcia, K., & Martin, D. (2014). Point-of-Care Ultrasound in Aerospace Medicine: Known and Potential Applications. Aviat Space Environ Med Aviation, Space, and Environmental Medicine, 730-739.
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- Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, part II: Current indications. J Emerg Med. 2011;40(3):313-321. doi:10.1016/j.jemermed.2009.11.028.
- Press GM, Miller SK, Hassan I a., et al. Prospective Evaluation of Prehospital Trauma Ultrasound During Aeromedical Transport. J Emerg Med. 2014;47(6):638-645. doi:10.1016/j.jemermed.2014.07.056.
- Chanler-Berat J et al. Typhoid intestinal perforation: Point-of-care ultrasound as a diagnostic tool in a rural Ugandan Hospital, Afr J Emerg Med (2016), http://dx.doi.org/10.1016/j.afjem.2015.09.004
- Heegaard W, Hildebrandt D, Spear D, Chason K, Nelson B, Ho J. Prehospital ultrasound by paramedics: Results of field trial. Acad Emerg Med. 2010;17:624-630. doi:10.1111/j.1553-2712.2010.00755.x.
- Walcher F, Kirschning T, Müller MP, et al. Accuracy of prehospital focused abdominal sonography for trauma after a 1-day hands-on training course. Emerg Med J. 2010;27:345-349. doi:10.1136/emj.2008.059626.