Advocating for change in the treatment of trauma patients in developing countries: Training emergency doctors in the use of bedside ultrasound is improving trauma outcomes in rural Nicaragua

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In Nicaragua, one out of six deaths results from traumatic injury. Not only does the country have the lowest income in Central America, but it also was the only county that showed a reduction in the overall expenditure on health as a percentage of the gross domestic product (GDP) from 7.5 percent in 1995 to 3.6 percent in 2001.

In January 2010, while researching international emergency medicine (IEM) elective sites for my hospital’s emergency medicine (EM) residency program in the Nueva Segovia district of Nicaragua, I was visiting the local hospital in Jalapa when a 17-year old girl was brought into the emergency department (ED) with severe chest and abdominal injuries after being hit by a truck while walking on the road. She had multiple severe injuries, and required assisted breathing with a tube due to her comatose state. After assisting in stabilizing the patient, I rode in the ambulance with the Jalapa emergency doctor as we transported her to a larger hospital in Ocotal, Hospital Alfonso Mercada Guillen (HAMG), which had better capabilities to handle a patient with injuries of this severity.  On arrival the Ocotal ED doctors, whose concern was that she might have internal bleeding, assessed the patient, but unfortunately there is no imaging modality available there to diagnose this type of injury definitively.  The decision was made to transfer her to the large referral hospital in the capital city, Managua, which would take the ambulance approximately 4 hours drive.  There she could have CT scan or other diagnostic testing to determine the true extent of her injuries, followed by definitive management.  Tragically, she died en route to Managua.

I later learned that the Ocotal district hospital possesses a portable ultrasound machine, donated previously by an NGO, which is only used in the Labor & Delivery Ward.  In the US, use of bedside ultrasound has become standard of care in the initial evaluation of trauma victims, with a 93-97% sensitivity for detecting intra-abdominal or intra-thoracic bleeding, taking only minutes to perform by the ED doctor, and gathering vital information about patients who are too unstable to be transported out of the trauma bay to the radiology department for Computed Tomography (CT) scan, the gold standard imaging test for intra-abdominal and intra-thoracic injury.  Had the ED doctors in Ocotal been able to utilize the ultrasound machine that was already in their hospital, it could have shown that the girl’s injuries were too severe to survive the long drive to Managua, and that she required immediate intervention by the Ocotal surgical team.  Given her many severe injuries, it is of course not possible to know whether such surgical intervention could have saved this patient’s life, however it is clear that the information obtained by an ultrasound in these types of situations could significantly benefit the ED team with the difficult decisions that they make every day.

After discussing this case with the Ocotal hospital Director, and in partnership with the local SILAIS (El Sistema Local de Atencion Integral en Salud), I have proposed implementation of a new policy to use bedside FAST (Focused Assessment with Sonography in Trauma) exam to rule out intra-abdominal or intra-thoracic injury in trauma patients, and the training of emergency care health practitioners to perform the FAST exam and make clinical decisions based on the results.

Previous studies looking at ways to strengthen trauma care in developing countries have shown that basic ultrasound skills such as the FAST exam can be effectively taught to physicians in a short period of time. The WHO also recommends ultrasound for trauma in a statement paper that established standards for trauma care in developing and resource-poor countries.  Ultrasound use in these settings has been shown in previous studies done in Rwanda and Peru to be a sustainable and effective modality for decreasing morbidity from traumatic injuries.

In March 2011, I returned to Ocotal with two emergency medicine residents from my home hospital, Christiana Care Health System (CCHS) and conducted a pilot teaching program that trained physicians and residents from various medical facilities in the Nueva Segovia district, including those from the Ocotal and Jalapa hospitals, in the performing and interpreting the FAST exam. We used several portable ultrasound machines donated by Sonosite, Inc. through its SoundCaring program. The educational program was met with enthusiastic participation, and a subsequent research study of the program has showed that the local doctors were able to significantly increase their skills in using the US machine, as well as increase their comfort level in detecting abnormalities and signs of potential injury.  The international emergency medicine fellowship program at CCHS has now committed to collaboration with Hospital Alfonso Mercada Guillen in Ocotal, with the goal of continuing the educational program and evaluating the changes and improvements that come from the new protocol.  We hope that training health practitioners in the use of ultrasound in the initial evaluation of patients suffering traumatic injuries in developing countries could lead to early diagnosis and treatment, and reduction of deaths from treatable traumatic injuries.

In the past decade, collaborations of this type in other areas of Nicaragua have shown to have a “dramatic positive impact on the quality of emergency care provided.”

In particular, where rural hospitals have existing ultrasound devices for pregnancy cases, training the emergency department doctors in FAST exam and other US protocols would, I believe, prove very effective in reducing the effects of the high rate of death from trauma injury in Nicaragua.  This program is already shown effective in the small pilot described above, supported by one local hospital and the regional SILAIS. To implement this policy on a national scale would require support from the MINSA (Ministerio de Salud de Nicaragua) as well as ultrasound manufacturers and US teaching hospitals willing to conduct programs to train ED doctors throughout Nicaragua.

If implemented, the proposed policy could have an immediate impact and save lives. I advocate that relevant stakeholders here in Nicaragua and in the USA move forward with steps to make this happen, given that there are benefits for many involved parties: emergency medicine programs in the USA are able to provide their residents and fellows with educational opportunities aimed at furthering the specialty of emergency medicine, ultrasound manufacturers are able to promote their technology to a widespread population and ensure that doctors are trained in the use of these devices, and the Nicaraguan health care system in general will have fulfilled it’s mission to bring better care and reduce trauma-related deaths per capita for its citizens.

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2 Responses to “Advocating for change in the treatment of trauma patients in developing countries: Training emergency doctors in the use of bedside ultrasound is improving trauma outcomes in rural Nicaragua”

  1. yangli Says:

    This is a very thorough post. As a resident in Emergency Medicine, I would fully support an endeavor like that described in the above. FAST ultrasound is becoming the norm in modern day Emergency Departments around the world. It is quick to do and relatively easy to learn, given time for practice. Most Emergency Medicine Residency programs in Canada for instance, accomplish this training for residents within a 1-2 month span in a dedicated rotation. Although it is obviously very useful in detecting intra-abdominal free-fluid such as blood, the only aspect I would caution is obviously what the article already mentions – the sensitivity of the test. It is not a perfect test, and a negative test of course does not rule out intra-abdominal bleeding. Thus in some situations, if a patient needs to be transported to a site where a CT scan should be performed, given the clinical situation, then it still needs to be done. This is a minor point given the purpose of the blog/article however. I applaud the efforts that have already been made in the situation described.

  2. faminerelief Says:

    This is truly live saving policy in advancing trauma care in a developing country. Towards the end of my surgical training in 2004-2005 in a Saudi Arabia, we started using FAST ultrasound in our trauma patients instead of the old age technique of a DPL. It was a major step forward in improving the care of our trauma patients, while there is still a need for a CT scan in some cases. a positive FAST ultrasound in an unstable patient or borderline patient will answer the question of immediate OR in a timely manner that ultimately would save a life!
    This is truly a great achievement and your efforts will benefit soo many!

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