Ultrasonography for the Busy Orthopaedic Surgeon: The Upper Extremity.

Ultrasonography is increasingly used in the diagnosis and treatment of musculoskeletal conditions and injuries. Ultrasonography possesses multiple advantages compared with other methods of imaging, including low cost, lack of radiation exposure, speed, and means for dynamic examination. Because of these advantages, many orthopaedic surgeons are routinely using ultrasonography to diagnose musculoskeletal conditions of the upper extremity. Musculoskeletal ultrasonography is technically challenging, but with proper guidance and practice, every orthopaedic surgeon can confidently integrate ultrasonography into their clinical practice.

Ultrasonography for the Busy Orthopaedic Surgeon: The Lower Extremity.

Ultrasonography has the potential to become a fundamental component of the diagnosis and management of musculoskeletal conditions and injuries. Moreover, in the context of modern healthcare systems that are focused on optimizing value, ultrasonography has the advantage of minimizing costs when compared with other advanced imaging modalities. Because of its low cost, lack of radiation exposure, speed, and capability to diagnose dynamic conditions, more orthopaedic surgeons are routinely integrating musculoskeletal ultrasonography into their daily practice. It is important to provide a comprehensive review of and approach to common musculoskeletal conditions of the lower extremity for the busy orthopaedic surgeon.

False Elevation of Volume Determined by Bladder Scanner Secondary to Bowel Obstruction.

Bladder scanners allow for quick determination of bladder volumes (BV) with minimal training. BV measured by a machine is generally accurate; however, circumstances exist in which falsely elevated BVs are reported. This case details a patient with a significant small bowel obstruction (SBO) due to superior mesenteric artery syndrome causing a falsely elevated BV. We believe this is the first case report of a SBO causing an elevated BV by bladder scanner. Emergency physicians should be aware of the pitfalls of using bladder scanners, and use their point-of-care ultrasound skills when possible to expand their differential.

Topical tranexamic acid (TXA) for the management of a bleeding arteriovenous fistula.

Tranexamic acid (TXA) is increasing in use in the Emergency Department (ED). While its topical uses have largely been observed in the management of epistaxis, other applications are utilized. We present a case of an 84 year old male with a bleeding arteriovenous fistula, responsive to topical application of tranexamic acid. This case report demonstrates another novel application of TXA in emergency care.

Hyaluronidase-Assisted Resuscitation in Kenya for Severely Dehydrated Children.

BACKGROUND: Dehydration, mainly due to diarrheal illnesses, is a leading cause of childhood mortality worldwide. Intravenous (IV) therapy is the standard of care for patients who were unable to tolerate oral rehydration; however, placing IVs in fragile, dehydrated veins can be challenging. Studies in resource-rich settings comparing hyaluronidase-assisted subcutaneous rehydration with standard IV rehydration in children have demonstrated several benefits of subcutaneous rehydration, including time and success of line placement, ease of use, satisfaction, and cost-effectiveness. METHODS: A single-arm trial assessing the feasibility of hyaluronidase-assisted subcutaneous resuscitation for the treatment of moderately to severely dehydrated individuals in western Kenya was conducted. Children aged 2 months or older who presented with moderately to severely dehydration clinically warranting parenteral rehydration and had at least 2 failed IV attempts were eligible. Study staff received training on standard dehydration management and hyaluronidase infusion processes. Children received all other standards of care. They were monitored from presentation and through discharge, with a 1-week phone follow-up. Predischarge surveys were completed by caregivers, and semistructured interviews with providers were performed. RESULTS: A total of 51 children were enrolled (median age, 13.0 months; interquartile range of 18 months). Fifty-one patients (100%) had severe dehydration. The median length of subcutaneous infusion was 3.0 hours (interquartile range [IQR], 2.95). The median total subcutaneous infusion was 700.0 mL (IQR, 420 mL). Median time to resolution of moderate to severe dehydration symptoms was 3.0 hours (IQR, 2.95 hours). There were no significant complications. CONCLUSIONS: Hyaluronidase-assisted subcutaneous resuscitation is a feasible alternative to IV hydration in moderately to severely dehydrated children with difficult to obtain IV access in resource-limited areas.

Topical use of tranexamic acid for the management of post-procedural rectal bleeding.

Tranexamic acid (TXA) is increasingly used in the Emergency Department (ED). While the intravenous form has been extensively studied and used, it's utility in a topical formulation is not as widespread. Its reported use in the ED is mostly for control of epistaxis. We present a case of a 61 year old male with post-procedural rectal bleeding, responsive to topical application of tranexamic acid. This case report demonstrates another novel application of TXA in emergency care.

Patient Characteristics from an Emergency Care Center in Rural Western Kenya.

BACKGROUND: Emergency care is a neglected area of focus in many low- and middle-income countries. There is a paucity of research on types and frequencies of acute illnesses and injuries in low-resource settings. OBJECTIVE: The primary objective of this study was to describe the demographic characteristics and emergency conditions of patients that presented to a new emergency care center (ECC) at Sagam Community Hospital in Luanda, Kenya. METHODS: Patient demographic characteristics, modes of arrival, chief symptoms, triage priorities, self-reported human immunodeficiency virus status, tests performed, interventions, discharge diagnoses, and dispositions were collected for all patients that presented to the Sagam Community Hospital ECC. RESULTS: Between October 1, 2016 and September 30, 2017, 14,518 patients presented to the ECC. The most common mode of arrival to Sagam Community Hospital was by foot (n = 12,605 [86.8%]). There were 8931 (61.5%) female patients and 5571 (38.4%) male patients. Of the total visits, 12,668 (87.3%) were triaged Priority III (lowest priority), 1239 (8.5%) were Priority II, and 293 (2.0%) were Priority I (highest priority). The most common chief symptoms were headache (n = 3923 [15.2%]), hotness of body or chills (n = 2877 [8.8%]), and cough (n = 1827 [5.5%]). The three most common discharge diagnoses were malaria (n = 3692 [18.9%]), acute upper respiratory infection (n = 1242 [6.3%]), and gastritis/duodenitis (n = 1210 [6.2%]). CONCLUSIONS: Although opening an ECC in rural Kenya attracted patients in need of care, access was limited primarily to those that could arrive on foot. ECCs in rural sub-Saharan Africa have the potential to provide quality care and support attainment of Sustainable Development Goals.

Safety of a condom uterine balloon tamponade (ESM-UBT) device for uncontrolled primary postpartum hemorrhage among facilities in Kenya and Sierra Leone.

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal mortality in low- and middle-income countries. While evidence on uterine balloon tamponade efficacy for severe hemorrhage is encouraging, little is known about safety of this intervention. The objective of this study was to evaluate the safety of an ultra-low-cost uterine balloon tamponade package (named ESM-UBT) for facility-based management of uncontrolled postpartum hemorrhage (PPH) in Kenya and Sierra Leone. METHODS: Data were collected on complications/adverse events in all women who had an ESM-UBT device placed among 92 facilities in Sierra Leone and Kenya, between September 2012 and December 2015, as part of a multi-country study. Three expert maternal health investigator physicians analyzed each complication/adverse event and developed consensus on whether there was a potential causal relationship associated with use of the ESM-UBT device. Adverse events/complications specifically investigated included death, hysterectomy, uterine rupture, perineal or cervical injury, serious or minor infection, and latex allergy/anaphylaxis. RESULTS: Of the 201 women treated with an ESM-UBT device in Kenya and Sierra Leone, 189 (94.0%) survived. Six-week or longer follow-up was recorded in 156 of the 189 (82.5%). A causal relationship between use of an ESM-UBT device and one death, three perineal injuries and one case of mild endometritis could not be completely excluded. Three experts found a potential association between these injuries and an ESM-UBT device highly unlikely. CONCLUSION: The ESM-UBT device appears safe for use in women with uncontrolled PPH. TRIAL REGISTRATION: Trial registration was not completed as data was collected as a quality assurance measure for the ESM-UBT kit.

Evaluation of a ketamine-based anesthesia package for use in emergency cesarean delivery or emergency laparotomy when no anesthetist is available.

OBJECTIVE: To assess the safety of a ketamine-based rescue anesthesia package to support emergency cesarean delivery and emergency laparotomy when no anesthetist was available. METHODS: A prospective case-series study was conducted at seven sub-county hospitals in western Kenya between December 10, 2013, and January 20, 2016. Non-anesthetist clinicians underwent 5days of training in the Every Second Matters-Ketamine (ESM-Ketamine) program. A database captured preoperative, intraoperative, and postoperative details of all surgeries in which ESM-Ketamine was used. The primary outcome measure was the ability of ESM-Ketamine to safely support emergency operative procedures. RESULTS: Non-anesthetist providers trained on ESM-Ketamine supported 83 emergency cesarean deliveries and 26 emergency laparotomies. Ketamine was administered by 10 nurse-midwives and six clinical officers. Brief oxygen desaturations (<92% for <30s) were recorded among 5 (4.6%) of the 109 patients. Hallucinations occurred among 9 (8.3%) patients. No serious adverse events related to the use of ESM-Ketamine were recorded. CONCLUSION: The ESM-Ketamine package can be safely used by trained non-anesthetist providers to support emergency cesarean delivery and emergency laparotomy when no anesthetist is available.

Prevalence of unrepaired third- and fourth-degree tears among women taken to the operating room for repair of presumed obstetric fistula during two fistula camps in Kenya.

INTRODUCTION AND HYPOTHESIS: More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears. METHODS: Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya. RESULTS: One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33 %) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95 %) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51 %) women with OF symptoms ultimately had true OF confirmed at operation. CONCLUSION: These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

Uterine Transplantation: Ethical Considerations within Middle Eastern Perspectives.

The field of reproductive medicine witnessed a breakthrough in September 2014 with the first successful live birth post uterine transplantation. This success represents the culmination of decades' worth of research on infertility and reproductive medicine. This subject of infertility gathers special attention in the Middle East, as childbearing is given paramount importance in the family unit. And as with any new medical advancement, Middle Eastern people look to their religious authorities for guidance. This paper describes the various ethical quandaries related to uterine transplantation, from a perspective of the religious and societal factors that are unique to the Middle East, and embeds them within the conversation of its alternative solutions.

A Safe-Anesthesia Innovation for Emergency and Life-Improving Surgeries When no Anesthetist is Available: A Descriptive Review of 193 Consecutive Surgeries.

BACKGROUND: The worldwide human resource gap in anesthesia services often presents a barrier to accessing life-saving and life-improving surgeries. This paper assessed the impact of a ketamine anesthesia package, Every Second Matters-Ketamine (ESM-Ketamine)™, for use in emergency and life-improving surgeries by non-anesthetist clinicians in a resource-limited setting when no anesthetist was available. METHODS: We analyzed prospectively collected data from 193 surgeries constituting a pilot implementation of the ESM-Ketamine package, among three sub-district hospitals in Western Kenya. The study population comprises patients who required emergency or life-improving surgery when no anesthetist was available. Non-anesthetist clinicians in three sub-district hospitals underwent a 5-day training course in ESM-Ketamine complemented by checklists and an ESM-Ketamine Kit. Data were collected prospectively every time the ESM-Ketamine pathway was invoked. The training cases, although primarily tubal ligations, were included. The primary outcome measures centered on capturing the ability to safely support emergency and life-improving surgeries, when no anesthetist was available, through invoking the ESM-Ketamine pathway. The registry was critically examined using standard descriptive and frequency analysis. RESULTS: 193 surgical procedures were supported using the ESM-Ketamine package by five ESM-Ketamine trained providers. Brief (<30 s) patient desaturation below 92% and hallucinations occurred in 16 out of 186 (8.6%) and 23 out of 190 patients (12.1%), respectively. There were no reported major adverse events such as death, prolonged desaturations (over 30 s), or injury resulting from ketamine use. CONCLUSION: This study provides promising initial evidence that the ESM-Ketamine package can support emergency and life-improving surgeries in resource-limited settings when no anesthetist is available.