International Health Studies Grant 2013-14 in Action: Refugee Health Clinic on the Thai-Burma Border

Development of an Ultrasound Training Program at a Refugee Health Clinic on the Thai-Burma Border

Brian Guercio, MD PGY-3
Boston Medical Center/Boston University Emergency Medicine Residency

The project:

This is the second year of a multi-year, resident-led project to develop a training program to expand, enhance, and formalize the use of point-of-care ultrasound (POCUS) at The Mae Tao Clinic (MTC), a refugee health clinic on the Thai-Burma border.  

POCUS has been shown to have great utility in low-resource settings.  POCUS has the potential to greatly improve the diagnostic and therapeutic capabilities at MTC.  Useful applications at MTC include E-FAST scan in trauma, ultrasound-guided regional anesthesia, evaluation of abdominal pain, and assessment of renal and cardiac function for a variety of chronic and endemic tropical diseases.  

This project is unique because Emergency Medicine (EM) residents provide the training for MTC medics.  Other notable features of the project include the longitudinal presence of EM residents at the clinic and a “train-the-trainers” approach.  The training curriculum is based on the American College of Emergency Physicians (ACEP) guidelines for ultrasound training in Emergency Medicine residency, the Partners-In-Health Manual of Ultrasound for Resource-Limited Settings, and an informal needs-assessment conducted in 2010.

Last year, we introduced the project and training program at MTC and the results were encouraging.  This year, we improved the training curriculum and made significant towards a fully sustainable POCUS program at MTC.  Details are below.

The facility:

MTC provides a comprehensive array of medical and social services, but is extremely limited in its actual resources.  For example, aside from ultrasound, there is no routinely available imaging.  There are adult and pediatric departments as well as mental health services and housing for orphans and victims of domestic violence.  The medical staff is primarily Burmese refugees who are trained in-house or who had prior medical training in Burma along with visiting Western and Asian medical providers and students.

The participants/trainees:

The participants in our training program are medics who work at MTC.  Patients are at the clinic include Burmese refugees, displaced people, and undocumented workers.  Patients are not involved in the project.

Prior performance (2012-2013):

Last year, we established the training program.  Two 3-week training sessions were offered and we trained 36 medics in basic, high-yield POCUS techniques.  Trainees who completed the training course improved in both written and practical tests of POCUS knowledge and skill.  Also, we were able to establish our credibility at MTC and develop buy-in among the medics which facilitated our return to MTC this year.

Summary of project activities and outcomes (2013-2014):

This year, our primary goal is to make the training program self-sustaining and self-contained within the clinic, so that effective use of POCUS is not dependent upon visiting medical providers.  We made significant progress towards this goal.  So far, we completed 3-week training sessions in October and December and we plan for two more residents to go to MTC in May.  

During the October training session, I trained 33 participants in basic POCUS and 13 participants in advanced POCUS.  In total, 31 participants who completed the training course improved in both written and practical tests of POCUS knowledge and skill.  As compared with last year, the absolute improvement in numerical test scores was greater and the rate of participants who completed the training course was higher.

In October, I also began to transfer training responsibilities to clinic staff by involving the most advanced medics as translators, assistants, and exam proctors.  Also, these medics expressed interest in being members of the formal ultrasound committee to be established at the clinic.  

During the December training session, another resident provided focused hands-on training for 24 participants, most of whom participated in the October training session.  These medics were identified by prior practical test scores as likely to benefit from skill-based, as opposed to lecture-based training.  All participants who completed this hands-on training program improved on a practical test of POCUS skills.

Also in December, we introduced a standardized ultrasound report form.  This simple form is significant for several reasons described below.

Finally, we have submitted two abstracts to EM conferences based on data collected as part of this project.  We plan to put together a third abstract that incorporates all data collected thus far.

Lessons Learned:

The potential impact of establishing a training program for POCUS is significant, but not surprising.  What I did not expect, though, was how a simple effort to improve one aspect of the training program- the reporting of ultrasound results- would influence patient care at a systems level.  

I also learned that persistence results in acceptance.  Our previous investment of time and effort was rewarded this year when I was invited to take part in meetings with the clinic administration to develop a long-range plan for POCUS at MTC.

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