Calla Brown (MP3) talks about a joint effort to continue a project started by Ben Trappey

Posted on behalf of Calla Brown (MP3)

While Abby has been teaching ultrasound at St. Damien's, Hope, Adam, and I have been working on an evaluation project of a protocol for the admission of pediatric patients with severe acute malnutrition.  Ben Trappey, who is currently a Med Peds faculty member, our faculty advisor for the rotation, and also in the department of global pediatrics, did a four-week rotation at St. Damien's during his Med Peds residency.  While here, he worked with the staff to design an order set for malnutrition.  The order set was based on both the World Health Organization standards for the treatment of acute malnutrition and also on the Haitian Ministry  of Health protocol, and includes best practice guidelines like appropriate rehydration, feeding, and vitamin supplementation.  The staff at St. Damien's, including nurses and physicians, underwent an intensive training on its use in April of this year.  

One of the attendings asked us to evaluate the use of the order set.  We are evaluating two outcomes:  whether the order set was initiated upon admission to observation and whether the child survived to hospital discharge.  This evaluation is made easier by the department of Archives at St. Damien's.  All children who present with severe acute malnutrition, as defined by a weight-for-age Z-score of less than negative three or a weight-for-age Z-score of less than negative two with edema are entered into a book  and this data is eventually shared with the Ministry of Health.  

The Department of Archives

The Department of Archives has shared the book with us so that we can pull all of the charts from children admitted between January 1st and October 31st of this year.  From the chart we gather admission weight, gender, co-morbidities, and the above two objectives.  If the child did not survive to hospital discharge, we attempt to create a narrative history of the admission in addition to collecting objective data like vital signs, lab results, and blood sugar measurements, in order to understand as best as we can why the death occurred.  We will be collating and analyzing this data to share with the staff of St. Damien's.  Ideally together we will discover clinical correlates that could be intervened upon and then perhaps improve outcomes.  

Calla Brown (MP3) at The Department of Archives

Hope Pogemiller (MP4) at The Department of Archives

This quality improvement project has been interesting on many levels.  Firstly, we have seen many children who have been admitted for severe acute malnutrition, and in taking care of these children in partnership with the staff of St. Damien's, we have realized how critically ill a child with malnutrition can be.  Secondly, doing the project has inspired us to learn more about how treatment protocols for malnutrition were developed and what creative methods for its treatment have been implemented in different settings.  Thirdly, we have learned what a behemoth of a task it is to keep track of hundreds of thousands of paper charts in a navigable way.  We are still analyzing the data but we are excited to see what comes of this project.  Whatever the outcome, however, I think I can speak for all three of us when I say that we have learned a great deal.  

Abby Montague (PL3) creates a handbook on beside use of ultrasound

Posted on behalf of Abby Montague (PL3)

I am fascinated by ultrasound. In medical school I had the privilege of rotating at HCMC for an ultrasound rotation through the emergency medicine department. I spent a month learning everything from bedside FAST (Focused Assessment with Sonography for Trauma) exams and the basic bedside applications to looking for retropharyngeal (behind the throat) abscesses with intra-oral probe and confirming fracture reduction in the arm. Unfortunately, keeping these skills up during residency hasn't really been a priority due to the ready availability of excellent ultrasound technicians and pediatric radiologists. But I like looking at the images my patients get and guessing the diagnoses before the official read comes back. I occasionally would page through my Pocket Atlas of Emergency Ultrasound (by one of the HCMC faculty among others) to remember how I would do the studies myself.

Then I started preparing for Haiti.

Aside from X-rays, we knew an ultrasound machine was the only available imaging within the St. Damien's. I was excited about renewing my skills and asked Ben Trappey, our MedPeds hospitalist attending coordinating our trip, if the staff at the hospital would be interested in a little handbook on bedside use of ultrasound that I could do for my academic project.

They were.

After cramping my wrist at 5 am trying to get good RUQ views with the portable ultrasound in my call room, I had enough images for my project. I put together pictures of the buttons from our machines in the ED and on the floor for a mix of the way symbols appear and reviewed some radiology literature for images of clinical pathology. I printed up the guide on Saturday before we left and Ben presented it to our Haitian contacts when we arrived.

Ultrasound machine with Abby Montague's newly created bedside use of ultrasound booklet easily accessible on the side

One of the first ultrasounds we did here was evaluating a child with TB for pleural effusion (fluid around the lung). It was so grossly abnormal at first we couldn't find our landmarks. As we kept looking, we realized we were probably seeing TB cavitations within consolidated lung tissue (holes in the lung). It was impressive. The next was a child with abdominal distention who ended up having a complex cystic mass that was so large we couldn't tell if it was coming from the liver or the left kidney (on opposite sides of the body). Kids don't come to the hospital until they are really sick and their imaging findings, whether chest xray or ultrasound, tend to be dramatically pathologic. At first, the staff just asked us to go do the ultrasounds which couldn't happen until most people were gone for the day. Gradually, they started crowding around to look at the images in real time.

One of the new residents was the first to accept the transducer. Each ultrasound, I would pass it around to see if anyone wanted to practice, receiving a lot of smiling and head shaking with French explanations I couldn't understand. The resident, Renee, was admitting a child she suspected had intussusception (intestine stuck within intestine). After explaining my lack of training with intestinal imaging again (having attempted an appendix ultrasound the first week), I asked her to just start looking since we had equal lack of experience in this case. I shamelessly endorsed my ultrasound guide and showed her the pages about the difference between the probes and the standard probe positioning. She started scanning the abdomen and found a tubular structure with a target appearance in cross section. Never having ultrasounded a child before, she recognized the characteristic finding without prompting. The staff all came around to look and we had a long discussion about the next steps. With no fluoroscopy available, the child would need to have a reduction through an open abdominal surgery. A stunningly textbook history and suggestive abdominal film would have sent the child for reduction regardless. But I can't describe how satisfying it was to watch the resident add to her own clinical suspicion using ultrasound with minimal help.

One day I was asked to ECHO a cyanotic newborn. I am comfortable with the subxyphoid view but I couldn't remember the orientation of the alternative views of looking at the heart. The very same Pocket Atlas I used in MN had made its way to Haiti prior to our arrival and and I grabbed it from the stack of English textbooks on the registration desk to re-orient myself. Renee and I talked through the chapter on cardiac imaging, each tried a couple views and came to the conclusion the right ventricle was small and we could not determine much else. But the physician I had handed the book to was now flipping through other chapters to see what was possible with this machine they've acquired and now wanders in our direction to look over our shoulders whenever we bring the ultrasound out from radiology.

I have not stopped being completely anxious about people relying on our novicely obtained images. We are asked on a daily basis to ultrasound outside of our scope of familiarity - like the ECHO's for congenital heart disease, the intestinal ultrasonography, and examinations for biliary atresia. I've only turned down one request to look for peripheral pulmonary stenosis since I don't even know how to find the pulmonary arteries. But the giant septated pleural effusions are becoming more familiar and a new staff tried her hand at visualizing one today.

I've revived an old love and maxed out the space on my flash drive bringing home images to share with Ben. But I wish I had an image of the look on Renee's face when she found the right angle to visualize the heart. I felt like I really had brought something to give. Our Haitian colleagues have been most generous in sharing knowledge, skills, and gracious acceptance. My hope is that in this small way, we've shared something worthwhile in return.