Ultrasound advancement improving the quality of patient care around the world.
( Review of My ultrasound work in different countries, provinces and cities with some literature reviews).
Abstract
As portability and durability of ultrasound machines are improved, the bed side clinician-performed ultrasound is increasing . We are seeing increasing use of ultrasound procedures in rural, develop and underdeveloped parts of the world by doctors, midwives and trained nurses.
Physicians, nurses,midwifes, and medical officers have demonstrated the ability to perform and interpret a large variety of ultrasound exams.
I worked in different countries, lectured, presented cases, and did some cross training in so many overseas countries ,provinces and cities from 1975 until now ,including ;The USA , Canada , Middleast, Germany, Holland, Greece, Australia, Japan, South Korea, Singapore, Brunei, Malaysia , Indonesia, and Magnolia, anywhere between few week to few years as radiographer and sonographer. I had the opportunity to Ultrasound kings and queens, and members of royal families in Saudi Arabia, Brunei, Malaysia, and Jordan.
ultrasound use in the developing world and training guidelines currently in use, and highlight indications for emergency ultrasound in the developing world. More training and teaching of staff who practice sonography is important for bedside ultrasound use , and more research is need it to improve the diagnostic capacity and patient care in the most remote areas of the globe. Sonographers are encouraged to seek work in different part of the world to cross train and pass the sonography skill need it in many part of the world, working in different culture and experiencing different way of doing the task each day. You can use your skills to teach and gain new information while working overseas ,it is a rewarding courier that can benefit both you and the community you serve.
Background
I started my ultrasound courier right after graduation from Winnipeg health science center in1984.
I was working in the north part of Ontario, in moose factory.
I start working in Windsor Ontario-1984 to 1987, Reno Nevada, Palm Desert, and Indio California- USA, 1987, North BC covering terrace, Kitimat. Abbotsford -BC, and Vancouver –BC until 1991.
Saudi Arabia hofuf region- Alhasa, Khobar and dammam region 1992 to 1994, Jeddah region, in different time of my courier, Also covered Greece, Germany, Holland , Lebanon, turkey, and Iraq from 1975 to 1979 doing Radiology. Moved to Brunei in 1994,and did some cross training and lectures in Singapore, Malaysia and Indonesia ( south east ), Magnolia, Japan, and south Korea.
Did my echocardiography in Australia and worked in some clinics. Also Worked in Saskatoon, North Alberta High level, and surrounding cities.And moved to Calgary 2010.
I gathered so many facts and ideas , talked to so many sonographers from different part of the world and saw how they do the ultrasound task and handle daily problems, and witness the change of ultrasound technology from the contact scan era ,mechanical transducers to the present day ultrasound machines. o Also witness the improvement of the Radiologists and sonographers in regards to ultrasound educational progress and learning methods.
It was most wonderful experience to work with different people and culture and be part of this global ultrasound and the diagnostic health provider community.
In addition, I witness that machine design has become more user-friendly , compact, smaller and affordable With fewer knobs and streamlined design for quick comprehension of key features.
Many new laptop-based machines are now in production. Improvements in battery life for hand-carried
machines, and the lack of film, chemical developers and dedicated technicians, allow for use of ultrasound in health missions to remote areas of the developing world. Because of this evolution in technology and the growing body of literature to support its use, ultrasound has gained increasing recognition as a valuable diagnostic tool for resource limited settings by the ministries of health in different countries I visited, and by the world health organization -united nation.
Moose factory, North Ontario 1983
Moose Factory hospitals experience increasing number of self inflected trauma volumes in that region, we used to have limited ultrasound capabilities, with ATL 2, leading to significant diagnostic and therapeutic
Challenges , as I used to use saline bag to scan the thyroid and other small parts ,due to limitation of small part transducers .They had High number of frost bites and fingers imputations due to alcohol use and falling sleep outside in the street in a minus 40 degree temperature . High number of TB, fatty liver disease among men, and increasing PID and STD among teens with notable ectopic pregnancies.
The community was ruff and difficult to work for , with lots of stabbing, alcohol , and depression.
Windsor ,Ontario, 1984 -1987
I was working for Windsor regional hospital , it used to be called IOD hospital back then In 1984 , The Diagnostic department used to have a contact scanner machine, and old version of a mode scanner, ATL us early generation machine with mechanical transducer , and a Doppler machine that I used to do arterial Doppler depend on sound only with no imagine , so I used to listen and grade the stenosis depending on hearing only.
A high number of pancreatic cancer, renal cancer, and testicular cancer was diagnosed.Among it Thyroid tissue in dermoid masses in a lady with thyroidectomy. I started my shoulder ultrasound training with David MacDonald and I was providing shoulder ultrasound scanning since 1984.
Reno Nevada- USA, Palm Desert and Indio California 1987- 1989
We were spoiled , the as we use to have an old version of Acuson us machine, it was considered The Mercedes of ultrasound machines in that time. We had So many depression and stressful patients, and Reno had The highest suicide in the USA per capita in that time.
While in Indio California they live longer than other areas in that region. Most of our patients were Mexican immigrants, and in palm desert California most of our patients are VIP and other rich people. I had the opportunity to scan Bob Hope, Sonny Bono the mayor of palm desert, Betty white, and others. I noticed Lots of gallstones and renal stones among the Mexican population due to hard work under the sun and dehydration. I also was lucky to volunteer for the Sandiego zoo to assist the vet in scanning a gorilla liv er ,for abscess and Hydatid cysts.
North and south BC, Canada, 1989-1991
Covering Terrace, Kitimat, Abbotsford, and other private clinics in Vancouver.
The weather was a bonus, salary level is low and tax is higher than Alberta.
It was hard to find a full-time job, Syria, Syrias many departments and clinics try to avoid paying benefits In that Syria
Iraq , Egypt and Morocco
You will not find many of these problems if you decide to go to Lebanon, Syria , Iraq, culture, Morocco, and Egypt in those days.Each country has a culture, different pay scale, and they are much open mind than the Gulf states when it comes to western workers. They do speak English and French to some degree.
And If you done all your paper works, established your connection, and routine, then you can enjoy the new and different culture, great food and gain weight .They use Lira, Dinar, Jeneh, instead of rials and dirham. You can Google for Geography, history, and currency of each country before you decide to visit or find work. If you have a friend who knows a local family or someone local it will be a great help to start your journey. Many Canadians end up meeting their future significant other and got married.
I was working in Al Hofuf –AL Hasa, south east Saudi Arabia Region. I worked in this region from 1992 to 1994, ultrasound was introduced at Many rural district hospitals, and clinics, and the impact on patient care was assessed by asking providers to identify if ultrasound changed patient management plans. And the answer was positive. In those days we didn’t have Ppac or digital system.
The majority of scans were performed for obstetrical purposes and 80% of patients always ask for the female sonographer, for cultural reason, 20% of patients don’t mind male sonographers.
Many fetalmalformationsn were noted due the restricted genetic pools in that community due to the close relative marriages among that Shia minority , some of the fetal anomalies includes anencephaly, fetal cardiac and brain anomalies and uterine malformations. High Cholesterol and obesity now is an epidemic in Saudi and gulf states countries followed by diabetes, and it makes it more challenging to do the abdominal ultrasound .
while most male patients were sent for abdominal and small part sonography, renal us was a on top of the list, as there were increasing number of renal disease and malformations , stones and other renal pathology in that desert community.
Male and Female sonographers
Female sonographers are in high demands in most of the Muslim populated areas of the gulf states, Saudi.It is very difficult now days for a male sonographer to get a job in Saudi, only if he is Saudi Citizen, or if you get hired as a supervisor .
Restriction, and work environment in Saudi Arabia.
There are many restriction if you decide to work in Saudi Arabia , with 50% turnover staff from western countries, some leave and quit in 2 weeks time, some last less than 3 months, due to a cultural shock , hot temperature and high humidity, restriction on travel, parties, and driving.
Many of the Gulf states countries have a dress codes, don’t tolerate alcohol, immodesty in beech areas , especially in Saudi Arabia were parties are not allowed, if you don’t ask for permission first.
They don’t allow women to drive in Saudi yet, and for men it will take a long time to get your license ,cell phone and internet if you don’t have all your paper work in order.
Pets and cargo
Don’t take your pets even if they allowed you, it is the most shocking experience for the pets I ever experience. my 3 cats almost died and I managed to save them in the last minute with the help of a local vet. It cost me 5000 dollars for 3 cats cargo, vet papers, health documentations, and embassy approval.
Don’t ship your cargo to Saudi Arabia, or to some gulf states, it will take you up to 3 months to get your cargo back and you spend more money than the cargo amount to obtain all the paperwork’s, inspections, a ray of the cargo , and transportation. You also need some bribery money, to get what’s belong to you! I had to bribe officer, and lower rank guard to get my paper work, then you have to pay almost 2000 dollars to have some one from the country to go and act as a middleman to do all the paper for you. The country do this so they can make money and creates jobs. So it is more bureaucracy for us and more money for them.
It is more easy in united Arab emirates, Bahrain and Kuwait when it comes to driving, shipping and obtaining social media etc. Qatar almost like Saudi too.
Don’t think you are going to safe money , as you will end paying so many fees for so many documentations and registrations, utilities pay, phone bills, and you will spend more on site seen and traveling.
Most of the goods and items that you take for granted here are very expensive in Saudi. Don’t ever take Alcohol or any candies or chocolate with alcohol in it, same thing goes for Brunei and other Muslim countries . You are allowed to get some ration from your Embassy , or at Aramco site and other international organization who have a license and permission to do so.
Some Saudi people go to Dubai , Bahrain and Kuwait to more freedom life style in bars, movies, dance clubs and beech with mix gender if they are close to the eastern region, while those who live close to the western region they used to go to Egypt, Lebanon and Syria for more fun . Those who can afford it they fly to Europe.
Most of work places in Saudi are separated to male and female segregated rooms, lounge, etc.
You feel like you are living in an open prison.
Don’t believe what they tell you or what they offer you. Negotiate for more and you will get it , if the demand is high.
Try to ask for a locum job first , so you can have a chance to see the work place and make your mind before you bring your wife and kids, pets and cargo. It will take you less than 3 weeks to find out the facts.
Most Asians, Middle East and African workers can tolerate heat, humidity, Saudi harsh weather, and work condition, but not so when you come from western cool country.
Don’t ever leave before you done all your paperwork’s, otherwise you end up suffering for more than 90 days before you can get your documentations, in order for you to get cell phone connection, and other social media technology etc. Many western technologist leaves and never go back in the first few weeks.Some left all their belonging behind just to get rid of the bureaucracy and the harsh environment.
That’s why Saudi Arabia now makes It even more difficult for you to leave . You have to do the release form and that can take you up to 2 weeks.
From the moment you enter to the moment you leave the country you are a suspect , and when you decide to leave or resign, you have to do the paper trail for the relies form, almost 25 different stamps from each department to clear you , and so many signatures from the lower to the higher manager ,director, and security to release you.
You keep running between departments that are in different building and streets in the 40 degree heat and every time you think you reach the department you will find it closed down for lunch, tea break, prayer time etc.
Same goes with the banks if you don’t have your papers in order, forget to open an account in any bank or send money anywhere. So bureaucracy is at large .
You will have so many problems from the time you arrive to the airport, to the time you leave. Many people don’t go back after they take vacation , and those who go back they notice increasing level of depression, stress and anxiety. Your recruiter will not tell you all the truth.
Sleeping and noise
In Saudi Arabia your sleeping pattern will be changed in the first 3 months , as you have to adjust yourself to the heat and humidity , constant air con to cool down, and drinking lots of water there for going to washroom in the middle of the night , and if that wasn’t enough the call for the prayers 5 times a day with lowed speakers everywhere, and almost at 4 am will take those early hour of beauty sleep from you .
So when you wake up to go to work you look like a porcupine on steroids, so think twice before you decide to go to Saudi. I went to Saudi 3 times, and every time I said to myself never again , cause I trusted my recruiter. Only exception I make is if you work with Aramco oil company, As it is Run mostly by USA and western companies and the hospital follow north American protocols, and it has more friendly work environment
Jeddah , 1999
I was working in Jeddah in the west part of Saudi Arabia back in July 1999.It is much better working condition than east part of the country, close to red seas, more fun and relaxed people, with more opportunity to go to private beeches, easy access to travel .But it can be very busy place as it is the place where millions of people fly to hajj and go to Mecca throw Jeddah airport .
.In Jeddah I also noticed increasing number of Renal disease, and kidney stones . while the eastern part of Saudi in Dammam and Khobar I noticed more renal disease than western part of Saudi and more fetal malformation, liver tumors. And chest disease.
The number of Cataract eye diseases was high in East Saudi Arabia as I was doing ophthalmology sonography once a week, with the ophthalmology department . I had the opportunity to scan many royal family members and get the experience of going to the palace of the king and his family along with our radiologist.
Trauma ultrasound ; Lebanon and middleast
FAST (Focused Assessment with Sonography in Trauma), has been used routinely in the management of trauma patients worldwide as a rapid, noninvasive way to evaluate patients with thoracoabdominal trauma. The FAST scan can be performed within minutes at the bedside and can help in resource-limited settings with decisions regarding which patients require immediate operative care.
The FAST exam has been shown to decrease the time to operative intervention in a randomized controlled trial as compared to a standard clinical evaluation.
Patients that received FAST had a 64% decrease in the time to operative intervention, and decreased complication rates and hospital length of stay [30]. The sensitivity of FAST scans in detecting intraperitoneal hemorrhage is 75-78% and its specificity is 98-100%, suggesting it is a useful tool to confirm the presence of hemoperitoneum and hemopericardium [31,32].
Clinically, the FAST scan is particularly beneficial in the hypotensive trauma patient whose source of hypotension is unclear [33]. In addition to its use in resource-limited settings during routine clinical care, FAST is also useful in disasters and mass casualty scenarios.
When evaluating multiple severely injured patients in a disaster setting, FAST can aid in rapid triage of injured patients and guide operative care. For example, FAST during wartime in Lebanon was employed as a tool for soldiers suspected of having abdominal injuries to help triage them to operative intervention, computed tomography (CT) or clinical observation [34].
FAST has also been used by medical relief workers during multiple natural disasters in the past 2 decades, including the earthquake in Armenia in 1988 [35], Wenchuan, China, in 2008 [36], and Haiti in 2010
[37], and the tsunami in Indonesia in 2004 [38]. FAST is also valuable in a resource-limited setting where there is limited access to computed tomography.
Brunei and south east Asia
I Start working In Sultanate of Brunei FROM 1994 to 1999, for the Jerudong royal family medical center
It was located on the south china sea sandwiched between Sabah to the north and Sarawak
To the south Part of Malaysia , and west of Borneo Island of Indonesia.
The medical center was for the Royal family only along with the VIP, Ambassadors and top Brass , with 95% western staff . I was the ultrasound supervisor, we had to go 2 weeks butler school training for conducting our self in the presence of royal family, dress code and other manors that was extremely important to obtain your job. The country used to be more relaxed in that time with some restriction when it comes to alcohol, women can drive and you can leave the country and cross the border any time you want as long as you have your valid passport with you. They use Bruneian dollar, No tax, free housing, free 2 trips a year and educational leave and many other benefits and bonuses. You expected to be on site when your service is need it and sometimes you stay until dawn waiting for the royals, and then you have to come back to work at 8 am. It was wonderful life and work environment back then until 1999 when the country had some financial problems and the place was shut down.
Ultrasound machines used in South East Asia.
south east Asia uses many different ultrasound machines and the major supplies are Japan and Australia as it is closer and operate with the country with heavy presence, ultrasound machines such as; Toshiba ( Japan ), Diasonic ( Australia) , Vingmed
( Swedish), and many other machines such as Aloka, Accuvix, Medison, Sonos, Shimadzu, and Hitachi.
Driving is the same as in UK .People are more friendly and helpful.
You must visit Singapore, working in Singapore is difficult as the salary is less than Brunei
With expensive car insurance and high rent, but you can get your PR while working in Singapore for 2 years or more. Japan in other hand is more expensive than all south east Asian countries the people are the most polite people in the face of this earth, with much advance ultrasound machines and skills, the only problem is they have difficulty in speaking English .
South Korea is Second to Japan when it comes to the ultrasound advancement and skilled sonographers and one of the best in that region. Japanese have mild temper compare to south Korea in the rush hour traffic.
I presented Brunei when I got selected in Japan to present my research back in 1998
With the international radiological society , the minister of health and education attended the convention and they take high bride of supporting education and research.
Saskatchewan
I was working from end of 1999 to end of 2002
In Saskatoon royal university Hospital ,27 dollars an hour doing 20 patients a day
The Salary was a jock but the experience was great , we have a wonderful supervisor Gary Kutcher and good staff radiologists and they taught us allot of MSK and Vascular ultrasound skills. Weather was harsh in winter and I leave if to that. Salary now in the scale of 47 dollars an hour maximum in a hospital setting.
North Alberta- High level
It is the last city north of Alberta , 3 hours from NWT
I start working in high level hospital from Jan 2003 to Jan 2010.
I served 26000 people with one ultrasound machine for 7 years, covering
High level, john-dor, fox- lake, Lacrete , Zama, Garden river, meander river, fort vermilion and many other small towns. With mix community of Native Indians, and Mennonite are more visible .The hospital was belong to AHS when Alberta was divided to 9 health region, I left the hospital when AHS took over the province health system and made it one region there for cutting bonuses and
Makes it difficult to barging for high salary etc. I noted increasing number of testicular cancer, Liver cancer among the white population. Uterine malformation and renal malformation among the lacrete population. Fatty liver infiltration, gall stones, TB, std and pid among the teens of native Indians population.
Cardiac ultrasound
Focused echocardiography has an important role in assessing patients with cardiovascular compromise. It is useful in diagnosing pericardial effusion, assessing left ventricular ejection fraction, assessing volume status in patients with shock and delineating the etiology of cardiovascular collapse. In one study in the US evaluating patients with dyspnea of unclear etiology (i.e., after ruling out congestive heart failure, pneumonia, COPD, pulmonary embolism), pericardial effusion was found in 13.6% of patients [45].
The incidence of such effusions may be higher in communities where HIV and tuberculosis are
more prevalent. Research supports the ability of non-cardiologist physicians to accurately diagnose pericardial effusions. In a large study evaluating 515 high-risk patients with dyspnea, 103 had a pericardial effusion. EPs’ bedside echocardiography obtained the diagnosis
with a sensitivity and specificity of 96% and 98%, respectively [46].
Evaluating for deep vein thrombosis (DVT) is useful in patients with leg swelling/pain, crush injuries, prolonged immobilization, recent surgery and other pertinent risk factors. In resource-limited settings, due to the hypercoagulability of HIV-positive patients and the lack of routine prophylactic anti coagulation of hospitalized patients, bedside diagnosis of DVT is especially important in providing timely care. Ultrasound evaluation for DVT has-been shown to be successful by non-vascular specialists
ranging from novice to advanced users of ultrasound, and can be performed in just a few minutes at the patient’s bedside [54,55].
Procedural ultrasound
Obtaining peripheral venous access can be a challenge in any setting in patients with obesity, vasculopathy, hypovolemia/ dehydration or history of intravenous drug use. In patients where the traditional approach has failed, ultrasound can be used to visualize a target vein. Physicians
have demonstrated a success rate of 91- 97% with a decreased time to cannulation and improved patient
satisfaction, and a very low risk of accidental arterial puncture [67,68]. Nurses and technicians trained in this technique have demonstrated an 87% and 78.5% success rate, respectively [69,70].
developing world, and rates of death from nearly all types of injuries are higher in developing countries than undeveloped countries [76,77]. However, in resource-limited settings, the availability of blood for transfusion is likely to be limited, and the blood that is available may not be comprehensively
screened for infectious diseases such as HIV or hepatitis B. Therefore, it becomes incredibly important
to have an accurate estimate of blood loss in both trauma patients and obstetric patients in order to ensure that those who truly need lifesaving blood transfusions get them rapidly, but precious and potentially dangerous blood transfusions are only used when absolutely necessary. However, blood loss in both obstetric and trauma patients may be difficult to assess clinically. Patients may not develop supine or even postural tachycardia or hypo-tension until they have lost a significant amount of blood volume [78].
Dehydration
Dehydration due to diarrhea is one of the leading causes of death in children under 5 in the developing world, responsible for nearly 2 million deaths (19% of all child deaths) each year [86]. In addition, epidemic diarrhea can kill thousands of children and adults in a matter of days or weeks in the setting of disasters and humanitarian emergencies, as evidenced by the recent cholera epidemic
in Haiti. As the severity of diarrhea can vary widely in these settings, accurately assessing dehydration status remains a crucial step in preventing mortality from this disease. While patients with severe dehydration require immediate treatment with intravenous fluids to prevent hemodynamic compromise, organ ischemia and death, a large meta-analysis found that children with mild to moderate dehydration have a significant reduction in hospital length of stay and fewer adverse events when treated with relatively inexpensive oral re-hydration solution (ORS) as compared to treatment with costly intravenous
fluids [87]. Unfortunately, the diagnostic tools available to physicians and other providers to assess the
degree of dehydration in children with diarrhea are limited. A recent meta-analysis of 13 studies found that no individual clinical sign or symptom demonstrated adequate sensitivity, specificity or reliability for detecting dehydration in children [88]. A similar meta-analysis in adults found clinical measures of dehydration to be even less useful [78].
Ultrasound may be a better measure of dehydration in patients with acute diarrhea. In children, since the size of a the IVC varies with age, research is currently focusing on the aorta to IVC ratio as a measure of volume status; the aorta provides an internal control for IVC since it does not change much in size with dehydration. In a recently published study of 52 children presenting to hospitals in rural Rwanda with diarrhea and/or vomiting, the aorta/IVC ratio had an area under the Sippel et al. International Journal of Emergency Medicine 2011, 4:72 http://www.intjem.com/content/4/1/72 Page 8 of 11
Edema in children
Edema is a common presenting complaint among children in low-income countries. It can be due to hypovolemia, such as in the settings of congestive heart failure secondary to rheumatic heart disease or renal insufficiency, or it can be due to low oncotic pressure from a nephrotic syndrome or protein-energy malnutrition (kwashiorkor). Indeed, patients with severe protein-energy malnutrition may appear edematous at the same time as they are actually intravascularly dehydrated, making it difficult to adequately assess their volume status on physical exam. Two studies from pediatric nephrology clinics in Poland and Israel suggest that ultrasound of the IVC may be useful for differentiating hyper- volemia from edema secondary to low oncotic pressure, which could prove useful in guiding further diagnostic testing and management of patients in resource-limited settings.
Cerebral malaria
Novel research from the pediatric acute care unit of Mulago Hospital in Kampala, Uganda, shows ultrasound of the optic nerve sheath diameter (ONSD) may be predictive of cerebral malaria in children. In this study, 33 children diagnosed with P. falciparum underwent targeted ultrasound examinations of optic nerve sheath diameter, color trans cranial Doppler insonation of the cerebral vasculature, cardiac ultrasound and abdominal ultrasound to evaluate spleen size. Increased optic nerve sheath diameter was observed in one third of all patients with malaria and in 100% of the patients with cerebral malaria, and after successful treatment showed return to normal size [8].
Conclusions
Trained nurses, midwifes, and Clinician-performed bedside Ultrasonography is emerging as a useful diagnostic tool for healthcare providers in resource-limited settings.
Much of the research to date supports the use of this technology to guide management plans and procedures; however, comprehensive, long-term studies have not been performed.
As further research emerges to evaluate the impact of ultrasound in resource-limited settings it will be possible to draw conclusions about the long-term sustainability of ultrasound programs in the developing world, target populations who may benefit most from ultrasound services, and further expand the indications for its use.
More training and teaching of staff who practice sonography is important for bedside ultrasound use , and more research is need it to improve the diagnostic capacity and patient care in the most remote areas of the globe. Sonographers are encouraged to seek work in different part of the world to cross train and pass the sonography skill need it in many part of the world, working in different culture and experiencing different way of doing the task each day. You can use your skills to teach and gain new information while working overseas , it is a rewarding career that can benefit both you and the community you serve. We must be flexible tolerant and understanding individual when working in a different work environment with different people and culture. The improvement in ultrasound technology is helping to provide the sonographers and doctors with faster diagnosis , better imaging capability with affordable budget.
Thank you for reading,
Steve Ramsey ( Saad Ramzi Ismail ) Ph.D.
Calgary, Canada