This post is the second part of Dr. Jonathan “Jono” Henry’s report from the Pacific nation of Vanuatu. Be sure to read the first chapter of his remarkable report.
Out in the peripheries, supply chains fail frequently: depleted electrolyte reagents, exhausted medication supplies, emptied oxygen tanks, or a single broken part rendering the X-ray machine dormant for months on end. Power outages occur regularly, and disasters such as volcanic eruptions, earthquakes, and cyclones disrupt inter-island transport and retrieval plans. These interdependent systems running at maximum capacity on a small budget are prone to failure, and frequently stall a patient’s emergency care.
In contrast, a battery-powered portable ultrasound machine operates as a powerful piece of standalone technology, and can be the deciding factor in a patient’s course. One case in particular illustrated the advantages of portable ultrasound.
“Anna” (not her real name) is a mother in her twenties with two young children. Two days prior, she’d begun to complain of lower abdominal pain and felt dizzy and disoriented. She was certain she couldn’t be pregnant, as her cycle had seemed normal.
She was brought in to the emergency department on a Sunday night, looking pale and distressed. Her abdomen was mildly distended and diffusely tender. In front of the nurses’ eyes, her condition worsened as her blood pressure plummeted. She then became unresponsive. The staff suspected the worst case scenario—a ruptured ectopic pregnancy. A senior gynecology doctor living nearby was available and ready to perform a life-saving operation immediately.
But confirming the diagnosis was essential. Anna was adamant she wasn’t pregnant, and we needed to be sure that a gynecologist was the right surgeon to operate. How could we prove she was pregnant, and furthermore, that the fetus was lodged in the wrong site?
Perhaps a blood test to check her hormone levels? Lab staff were on-call over the weekend, and calling them in would take some time. A urine dipstick pregnancy test? Currently we were out of stock. Maybe call in the on-call sonographer, and wheel the patient around to the bulky stationary ultrasound machine next door? We couldn’t keep resuscitating her in that cramped radiology room, plus we didn’t have time. Anna looked like she may bleed to death any minute.
Bedside ultrasound was the key here. As I watched over their shoulders, one of the Ni-Van interns, recently upskilled in the basics of eFAST and obstetric scanning, was able to immediately identify a large volume of anechoic fluid pooling around Anna’s liver. A small fetus was found with the probe just below her belly button, and was lodged at an unusual site, just outside the womb.
A blood transfusion was started, the theater team mobilized, and Anna was whisked down the hall to the operating theater. The gynecologist began their work with an incision low in the abdominal wall. This operation couldn’t be started laparoscopically, as none of the necessary equipment was available in Vanuatu. Bleeding, bleeding, uncontrollable. Everyone grew quiet as the life-threatening diagnosis was confirmed—a ruptured cornual ectopic pregnancy. Clamps, suction, sutures, more clamps, more sutures. Nothing could stem the flow of blood coming from Anna’s pelvis. Under pressure, the gynecologist had to make the difficult decision. To save Anna’s life, her uterus had to be removed.
The next morning, Anna awoke in the ward, family at her side, blood transfusions continuing, her belly still tender from the events of the prior evening. Her gynecology team had to gently break the news. Her childbearing days were over. But looking over to her family, she saw the alternative would have been so much worse. Her husband, bringing up her two young boys alone.
Bedside ultrasound had played a critical role in the staff’s life-saving efforts that night. As Anna had laid in the ED, quietly exsanguinating with no immediate access to radiology and laboratory resources, young doctors with basic scanning skills and a machine the size of a laptop had sped her pathway to the OR and defused the deadly time bomb within her.
Most of the work here at Northern Provincial Hospital ED doesn’t come with such high drama, but the utility of POCUS is apparent all the same on a daily basis. When an older man flies all the way from an outer island with a stubborn in-dwelling catheter stuck in place, urological troubleshooting leads to an ultrasound-guided suprapubic balloon puncture. For a small child with a fractured thigh bone, an ultrasound-guided nerve block helps him through his first scary night in a hospital, and allow the painful process of traction to begin. And when the X-ray machine breaks down for a few months, the ultrasound machine becomes indispensable. Clinicians rely heavily on the M-Turbo to confirm their suspicions of bone fractures, pneumonias, cardiac failure, and more.
I emailed Sonosite’s Australasian team, telling them “Everyone here insists I’ll need to leave the machine behind when I leave!” And I’m delighted to report that’s exactly what Sonosite has done. Emergency physician Dr. Vincent Atua, currently the sole specialist at the busy VCH ED, is already using the M-Turbo to train Vanuatu’s next generation of emergency physicians in point-of-care ultrasound.
The process of POCUS training shouldn’t be trivialized. Image acquisition, interpretation, and integration are not skills learned overnight. Making Vanuatu EM’s future leaders ultrasound-savvy will take equipment, expertise, creativity, and perseverance. But as all those practicing emergency medicine in resource-limited settings know, the benefits of portable ultrasound will make this pursuit worthwhile.
By continuing to partner with generous companies such as Sonosite, I hope that portable ultrasound equipment and skills will continue to spread throughout Vanuatu’s 83 islands to provide faster, better emergency care for all Ni-Vanuatu patients.