WILDERNESS MEDICINE Balancing Sustainability With Pointof-Care Ultrasound Needs in Samoa

By Lorenzo Albala, MD on behalf of the SAEM Wilderness Medicine Interest Group

The audience laughed as the words “WE NEED UPSKILLING” unexpectedly filled the screen only a few slides into Dr. Nolan Fuamatu’s presentation on the state of emergency medicine in Samoa. It was not until several months later, when I was spending my days in the emergency department (ED) in Samoa, that I began to truly understand what he meant.

Samoa is a Polynesian island country halfway between Hawaii and New Zealand with a population of approximately 218,000 between its two islands. There are six emergency doctors in the entire country, four of which are pursuing emergency medicine certificates — the equivalent of a U.S. residency. Most have been practicing for several years in the ED at Tupua Tamasese Meaole, the country’s main hospital. The concept of emergency medicine specialization is in its infancy in Samoa, and with no in-country training, the “junior” registrars must travel to Fiji and New Zealand for rotations. After speaking with Dr. Nolan, I found out that he, like other trainees, had a six-month ED rotation at Savaii Island’s main hospital as an intern, managing the department by himself. Due to staffing shortages, this assignment morphed into a threeyear administrative posting where he effectively managed the entire hospital.

I quickly learned that emergency physicians (EPs) in Samoa are incredibly hardworking and mostly self-taught, operating with very constrained resources and trained with virtually no attending supervision. After several zoom calls with Dr. Nolan, we identified their greatest pain points: convincing consultants to staff or admit patients and struggling to obtain advanced imaging. Point-of-care ultrasound

(POCUS) was one thing we believed could help. The crew of Samoan EPs did not have an easily accessible ultrasound system, nor did they have any significant ultrasound training, and so our plan coalesced into three steps:

1. Develop a curriculum of virtual lectures covering POCUS principles and emergency ultrasound applications;

2. evaluate various strategies to acquire a dedicated ultrasound system for their department; and

3. spend four weeks in the field providing teaching and hands-on clinical POCUS training.

Fast forward to mid-April 2023: I wake up to an alarm of roosters and crickets floating through the open wall of my fale, a traditional thatched hut. I send the group a WhatsApp message: the ultrasound device purchase will be co-funded by St. Vincent’s Pacific Health Fund and the secretariat of the Pacific Community. My grant applications, over six months in the making, have finally been approved. I was overwhelmed with relief: the training we had done so far using my handheld ultrasound would now be truly worthwhile.

During my time in Samoa, my daily routine consisted of snorkeling at the local marine reserve, eating local tarobased fare, and spending several hours in the ED with the on-shift physician. The case mix was diverse enough that we ran the gamut of emergency POCUS applications. When our shifts were light on ultrasound, I found that bread-andbutter teaching (shock, codes, airway management, etc.) was a crowd favorite, and both the EPs and medical students on rotation were always receptive to my back-of-the-napkin talks.

Although my daily routine was comfortable, the resource-constrained practice often pushed me out of my comfort zone. “It is what it is” was often the reply to many problems. For instance, a shortage of adult laryngeal mask airways or neonatal oxygen masks were discovered during the most critical resuscitations. Other problems were more systemic: from the only critical care physician leaving the country to a scarcity of skilled nurses and no cardiac interventional or neurosurgical care. Although some of these issues had workarounds, one of the most frustrating roadblocks for the EPs centered around ordering CT scans. I still struggle to understand some of the “reasons” for why we could not get clinically indicated imaging: it is hard to convince the tech or radiologist to approve a scan after 6 p.m., the radiologist requires the surgeon be consulted prior to a brain trauma scan, or my personal favorite — the patient must be fasting for eight hours prior to an abdominal scan to “reduce gas.” These challenges were so pervasive that plain skull radiographs are standard of care in the head trauma workup.

Considering that the EPs only enjoyed 1-2 days off for every six shifts, I am sure the work often feels Sisyphean. I often wondered if some of these hurdles are common to settings where specialized emergency medical care has been and will be developed, where its pioneers are tasked with establishing the respect and legitimacy we enjoy in our field here at home.

Despite these challenges, community and family were immensely important for my colleagues, and truly for all the Samoans I met. Genuine hospitality and smiles were ubiquitous. I experienced a new level of close-knit family values, as well as an incredible respect for rest and religion. The communities and people of this country come together every Sunday and every evening to feast, pray, and be together. As a recent residency graduate, I was weaned on the many layers of isolation that accompanied the plague. In Samoa, every patient bed was always surrounded by at least five family members — fanning, massaging, and generally tending to their loved one. This sense of community was the drink I did not know I was dying for after a long time behind PPE.

I have given much consideration to the sustainability of global EM development, and specifically my efforts with this POCUS project in Samoa. I am now home, and I plan to return sometime in the next two years. The Samoan EPs occasionally send me scans to review through Whatsapp — agreeably not an ideal quality assurance (QA) system. However, when the staff is using gloves as venipuncture tourniquets and the ED is festooned with buckets positioned to catch water dripping from the ceiling — well, perhaps a robust QA system is low on the priority list. Is it better to not go at all, to avoid delivering an imperfect solution? Of course not.

Time and again, I saw the Samoan EPs use POCUS to reach a diagnosis, alter management, and leverage conversations with consultants, ultimately improving care. Often, POCUS was the necessary “ammo” needed to convince a consultant to see a patient, or to convince the radiologist to approve a CT scan. Towards the end of our second week, Dr. Baz decided to perform a bedside biliary scan on a patient, making the diagnosis of cholecystitis, all without my assistance. He smiled with a look that said, “this will change everything,” and called the surgeon. Dr. Agape noted free fluid on the scan of an early pregnancy patient and within one hour, the patient was in the operating room — an unheard-of disposition time. From bowel obstruction to RUSH (Rapid Ultrasound for Shock and Hypotension) exams and difficult IV access, patients who would have otherwise languished in the ED received better care. Perhaps most importantly, POCUS served a critical role in improving the confidence of our Samoan colleagues.

In a resource-constrained setting, providing health care can sometimes feel like an uphill battle. Providing a tool that increases emergency physician confidence and control over the patient’s care is not only empowering, but well worth it.

About The Author

Dr. Albala is a recent graduate of the Harvard Affiliated Emergency Medicine Residency and is currently a Wilderness Medicine Fellow at Massachusetts General Hospital. His interests include wilderness medicine education and global emergency medicine development. Outside of the hospital he is an avid surfer and kiteboarder.

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