Ultra-sound; ‘underused, under-trained,’ in SA

While this versatile point-of-care tool costs between a fifth and one-tenth of a bulky traditional ultrasound machine, (and unlike costly X-ray, and CT scans, poses no potential patient harm), slashed budgets and overloaded curricula are thwarting attempts to bring it into mainstream practice at both pre-and post-qualification levels.

Just two of SA’s 10 medical schools have introduced ultrasound for fifth-year medical students, while Nelson Mandela University in Gqeberha, recently began teaching third years, and the University of Pretoria is expected to commence in January 2024. Most curricula are considered “too full,” to fully embrace it as yet.

There’s a small band of dedicated family medicine, emergency medicine and critical care physicians and anaesthetists who swear by POCUS (point of care ultrasound) and carry the device, stethoscope-like, on daily ward rounds. Many are self-taught or have made use of short courses put together by the Emergency Medicine Society of South Africa, for example.

Self-taught POCUS fan, Family Medicine physician, Dr James Porter, learnt how to use ultrasound out of dire necessity while serving as a medical officer and later as a Family Physician at the remote Madwaleni Hospital 100km from Mthatha.

“It decreases waiting times, gets to an accurate diagnosis faster and helps you perform the correct procedure more safely. It also helps you refer your patient out more quickly - and to the correct department. It addresses significant problems. Overall, it’s a no-brainer. More than that, it’s fun to use!”

Speaking from False Bay Hospital where he works, doing rural outreach to teach Family Medicine registrars whenever he can, he illustrates with just one of several patient scenarios how POCUS can make a difference.

A patient comes into a clinic with hypertension and apparent chronic lung disease from smoking. She’s having difficulty breathing. It’s a weekend and there’s no access to X-rays.

Says Porter, “using POCUS, you put the probe onto her chest and look to see if the lungs are wet or dry (presence of bilateral B-lines).”

“It immediately points towards whether it’s a respiratory problem from chronic lung disease or a heart problem. These are vastly different diagnoses and different emergency treatments. Right off, you can differentiate. Does she have heart failure and fluid on the lungs or chronic lung disease and a lung infection? They require vastly different treatment but can present in the same way.’

Says Dr Dawie Schoeman, an ICU specialist with a background as an emergency physician – and a stalwart at Livingstone Hospital in Gqeberha, “when I trained there was no ultrasound training. It was almost considered a taboo - you weren’t allowed to touch the machine unless a super-specialist was around.”

Schoeman helped draw up the ultrasound curriculum for third-year medical students at Nelson Mandela University 18 months ago - almost as soon as it opened its doors, and today co-ordinates their ultrasound training.

“It doesn’t just answer diagnostic questions - especially for undergraduates. It’s really integrative when it comes to anatomy and physiology in a clinical setting. Here you see it in real time. For undergraduates it integrates anatomy knowledge into clinical scenarios early on. We’ve based it on evidence mainly from the United States, where they’re seeing that teaching undergraduate students early on makes them better at doing it, and better at picking up things that seniors miss. If introduced at an early stage, it enhances that future doctor’s diagnostic capability phenomenally.”

Yet another adherent, Family Medicine practitioner, Dr Pierre-Andre Mans, formerly part of a dedicated band of physicians at Zithulelele District Hospital, one valley away from Madwaleni, won a Discovery Foundation Academic Fellowship to probe what ultrasound skills a district-level medical practitioner should have. Having garnered a postgraduate diploma in ultrasound six years ago, he says that as a tool, it stands to transform the way rural medicine is practised.

“When a patient presents with complex symptoms you can often exclude a lot of things with the proper use of ultrasound. It can instantaneously direct your management. What I like most about its use in a rural setting is you can work with your on-site lab and x-ray people, whom you know intimately, to get a discharge diagnosis within 24 hours for most patients,” he enthuses.

Mans says there’s currently negligible or no ultrasound training happening at under and postgraduate level outside of radiology and emergency medicine.

“The formal curriculum needs to embrace it. This is what lies at the heart of my research. Right now, there’s too much discrepancy in individual practitioner skill levels,” he adds.

Professor Elma de Vries; MBChB program coordinator at Nelson Mandela University Medical School and a founder member of the Rural Doctors’ Association of South Africa, (RUDASA), strongly backed Schoeman’s initiative when he proposed it.

Says de Vries, “to the untrained eye the images are just grey. If you can learn how to see a vein to put an IV line in when you cannot easily see, it’s a great help – besides its obvious diagnostic value. The emergency meds people love it, and obviously in obstetrics, ultrasound is very useful. We just don’t have enough ultrasonographers in the country who can do advanced ultrasound which the average doctor doesn’t usually do.”

Asked about the paucity of ultrasound teaching, she says it’s, “because curricula are so full. I’ve spoken to colleagues at other varsities and they’re keen to build it in, but it’s so difficult. We’ll carve out a space in clinical skills and build on this in years to come.”

Another Discovery Foundation Fellow (who won a grant for “Rural and Underserved Rural Areas”), is radiologist, Dr Vishesh Sood, who works at the Red Cross Children’s War Memorial Hospital, focussing on children with TB and abdominal complications.

It was also more difficult to obtain a sputum sample from children, while abdominal ultrasound was often requested when the vague diagnosis of “failure to thrive,” was made, TB being one possible reason, he added.

Sood’s research is aimed at standardising reporting of ultrasound exams for abdominal TB (indeterminate, normal, or likely to be TB), and clarifying the parameters for use of the investigation. He says radiologists and their colleagues working with children have become somewhat inured to the vagaries of abdominal ultrasound tests when it comes to the indications for TB - and the wide variation in reporting.

Porter’s entry point to POCUS was via Twitter in 2016 when he found an online hashtag #FOAMed (Free Open Access Medical Education).

“I didn’t have access to a formal training course. Only the Emergency Medicine Society of South Africa was offering any kind of training, but it was difficult to access it from the rural Eastern Cape. My learning was born out of necessity because of the lack of referral facilities at Madwaleni. It was almost impossible to refer a patient given the limited ambulance service and a completely overrun Nelson Mandela Academic Hospital in Mthatha, an hour and a half’s drive away where they had a single CT scanner.” he says.

“Ultrasound is particularly useful in avoiding radiation from CT scans in a young child, especially when access to MRI is limited,” he said.

All the clinicians interviewed agreed that developing remote support and teleguidance, while less ideal than on-site training, would be pragmatic in increasing POCUS use. Developing on-site ‘POCUS champions,’ was however vital.

“There are already initiatives in the rest of Africa. It’s a no-brainer, an easy win. I’d love someone to pay for me to go from rural hospital to rural hospital doing training,” he grinned - not entirely in jest.

Another significant advantage of POCUS would be the impact on SA’s current burden of litigation, currently running at R129bn (in audit) in medico-legal claims in the State sector alone, with obstetrics leading the field.