Dr. Jessica Schmidt
There are several factors to consider before approaching an international ultrasound project including everything from plug-outlets to sustainable partnerships. This chapter explores some initial questions to consider before you pack up your machine and go.
Assessing local interest
As with any new project, having interest and buy-in from the right people is key. Effectively evaluating a site before launching a project is critical and involves assessing not only the resource needs (do we have access to an ultrasound, do we have electricity?) but also baseline knowledge, attitudes and possibly other administrative limitations. Several projects will fizzle and fail after an initial and enthusiastic external team comes in to teach a lecture on ‘the use of the FAST exam’ only to be training providers who do not see trauma patients or do not have regular access to an ultrasound machine.
Starting the project with a conversation is a simple and efficient first step. This conversation should be held with key stakeholders including representatives from the administration, clinicians who will use the ultrasound and those who will be helping to develop the ultrasound project. This conversation allows for a consensus on the need and desire to implement the project and the opportunity to establish clear goals. The most effective projects will compliment other efforts to improve health delivery and have a specific and well-thought-out goal.
Finding out what you need
In addition to a conversation with stakeholders, a more formalized process is important to determine what is needed before a project begins. Needs assessments are often used in this initial planning phase and are important for several reasons. An appropriate needs assessment allows for a better understanding of baseline knowledge, interest and motivation, gaps in care and service delivery, and practical limitations. Important areas to cover in a needs assessment include: knowledge, perceived need, anticipated barriers and anticipated benefits. Often, external groups are initially excited to bring a new skill/expertise to a group in a limited resource area, but that skill may not fit well with the patient population or the local environment. For instance, teaching a course in point of care biliary ultrasound would not be very useful in a setting where the majority of patients are pediatric. In addition, not understanding local disease burden, such as intussusception or liver abscess, would also be amiss. It is important to remember that trainings and educational projects often take time and resources away from other clinical responsibilities and so should be weighed carefully against other local commitments.
Getting the right people
Another important consideration when starting a new project is the commitment and buy-in from local administration. Although a new project idea may sound wonderful over a drink after a clinical shift with a fellow physician, other important factors influence how successful a project will become (and stay) and involve input from managers and other administrators. Some critical elements that are important to negotiate ahead of time are: creating protected time to participate in trainings (and compensation if relevant), arranging for a space to hold trainings, coordinating with other departments that may be affected (radiology, surgery), inviting the appropriate people (sonographers, mid-level providers), and inviting the right ‘higher ups’ at the right time. This last point is one which may be often overlooked by North American teams who tend to under-appreciate some of the organizational hierarchies in other countries.
Keeping the momentum
While external groups often come in and offer expertise and training to great fanfare, the initial interest and enthusiasm may diminish after the group leaves. Involvement of a local NGO and/or an ultrasound champion can be vital to a program’s survival. Imagine, for example, implementing an ultrasound training program designed to teach mid-level providers to screen for mitral valve pathologies in children (identified, of course, by a previous needs assessment). A local NGO could assist by coordinating a monthly screening clinic or could work on networking with other smaller sites for case referrals. In this way, the infrastructure would be locally developed by those who know the system well, and the new ultrasound skills would remain in use. Ultrasound champions- individuals identified for their aptitude and commitment to the ultrasound project- are also a great local resource and are important to sustain skills and enthusiasm over time. An ultrasound champion would be important to help with refresher trainings and ongoing engagement with the project. (see Chapter 4).
The big picture
As ultrasound machines become better, smaller and cheaper, more external groups are willing and able to bring ultrasound to limited resource settings. Careful consideration of why your group is going, what it will bring, who it will target and how it will benefit the local population and keep going after you leave are important to think about in detail many months before you actually board a plane.