Providing Education in Ultrasound to Trauma Physicians in
Uganda.
Implementation of Focused Abdominal Sonography for Trauma at a
Ugandan Trauma Center
Specific Aims:
Aim 1: To provide a formal ultrasound training
course for Focused Abdominal Sonography in Trauma (FAST) to
physicians and allied health professionals staffing the casualty
ward in a major Ugandan trauma center, and to evaluate the
feasibility of implementing FAST into the standard of care.
Aim 2: To prospectively assess the incidence of specific
intraabdominal and intrathoracic injuries in Ugandan trauma
patients and determine the current management and outcomes of these
injuries.
Milestones:
Aim 1: In 2006, The Global Health Sciences Center at
UCSF funded a project to implement Focused Assessment with
Sonography for Trauma (FAST) at Mulago Hospital, the main teaching
hospital in Kampala, the capital of Uganda. A FAST course was
organized for surgeons of all levels at Mulago Hospital in Kampala,
Uganda. The course was conducted by two American College of
Surgeons-certified instructors Dr. Peggy Knudson and Dr. Rochelle
Dicker, in November 2006. In addition, Dr. Jennifer Wang (surgery
resident) assisted in running the course and teaching practical
sessions, as did Dr. Jeremy Durack (radiology resident). Dr. Durack
also arranged a secure server, working with the information
technology group at the UCSF-Makerere University infectious disease
collaboration, in order to transmit ultrasound images online for
review at UCSF. In addition, a medical student, Eric Chen from UC
Irvine was present and organized the hiring and training of two
research assistants who would be gathering retrospective and
prospective data for analysis.
All attending and resident surgeons at Mulago were eligible to participate in the training course and follow-up evaluations. The FAST course was given over 4 days with 20 hours of instruction and incorporated didactic lectures on FAST and trauma, as well as hands-on practical training on volunteers and patients, followed by a final practical exam. One portable ultrasound unit (Sonosite) was left on site for continued use. Remote proctoring by the instructors in the United States was then performed by evaluating uploaded, annotated ultrasound images from the secure server. The participants provide their interpretation of the images as well as the patient history, with the goal of becoming "certified" in the FAST exam.
Nineteen surgeons enrolled in the course. Nine described themselves as likely to use FAST occasionally and nine as likely to use it daily. All completed the practical exam with scores ranging from 2-5 (5 points maximum). In the first 6-week period following the course, 8 surgeons performed FAST examinations on a total of 58 patients. In 32 of these cases, the instructors reviewing the sets of images remotely have completely agreed with the interpretation of all four images. In the second 6-week period, 12 exams were performed. This attrition in use of FAST can be attributed to several factors. Security of the Sonosite machine was a major concern, and thus when the office was locked in non-working hours, the machine could not be used. The system at Mulago Hospital differs from that we are used to in the U.S., and surgeons are not the first to evaluate injured patients. Timely review was difficult, and surgeons at Mulago may have preferred to receive more real-time feedback.
Overall, the FAST training course was well received in this major trauma referral hospital in the capital of Uganda. The surgeons were adept at learning the FAST exam and incorporating it into their everyday practice.
Aim 2: In order to assess the impact of FAST on trauma patient outcomes, we planned to collect 12 months of data on trauma patients (6 pre-FAST and 6 post-FAST). However, the overall use of FAST was limited and thus we determined it would be difficult to truly evaluate the impact of FAST on trauma patient management during the time period reviewed. Therefore, analysis of the impact on trauma patient outcomes will take place pending increased use of FAST. An analysis of the potential cost-effectiveness of FAST was modeled, and this analysis is currently submitted for publication.
Work Plan:
Currently, a UCSF faculty member, Dr. Doruk Ozgediz, is based in
Kampala and continues to work with the Ugandan surgeons in
incorporating FAST into the daily routine. The Ugandan surgeons
hope to receive a more formal refresher course in the use of FAST.
Then, once FAST is being used more frequently, we plan to resume
collection of data regarding trauma patient management and
outcomes, in order to fully analyze the impact of FAST upon patient
care.
Publications/Presentation:
Ozgediz D, Wang J, Uyeno L, Jayaraman S, Ayzengart A, Vu L,
Jamshidi R, Goetz L, Dicker R, Knudson M, Schecter W, Farmer D.
"Surgical Training and Global Health: Results of a Four-Year
Partnership with a Surgical Training Program in a Low-Income
Country." Residents' Forum at Pacific Coast Surgical Association,
February 2008, San Diego, CA.
Wang J, Dicker R, Mabweijano J, Durack J, Ozgediz D, Chen E, Ezati I,, Knudson M. "Implementation of Focused Abdominal Sonography for Trauma at a Ugandan Trauma Center." Bethune Round Table, sponsored by the Office of International Surgery at the University of Toronto. May 2007, Toronto, Canada.