Chapter 3: Technical Aspects

Dr. Jessica Schmidt

Bringing new technologies and skills to other settings, especially low resource settings, brings numerous technical challenges. This section aims to provide insight and practical tips helpful in preparation and trouble-shooting.

Power sources and surges

Before you plug in the machine, you must understand the power source. In the United States, standard voltage is 120V with a frequency of 60 Hz. However, in much of Africa, Asia and South America, the standard voltage is 230V and 50 Hz. In addition, plugs and sockets also differ in shape. To use a US-based plug in another country, a plug adaptor is needed to fit the prongs into the appropriate holes. A simple plug adaptor; however, does not take into account differences in voltage, and a voltage converter is needed. For plug adaptations, you can either buy a simple plug adaptor, or ask for a cable with the correct plug end (e.g. ask for a machine with a G-type plug for use in Uganda). The voltage is a trickier issue. It is important to contact your machine representative to ensure that the ultrasound machine can handle the voltage/frequency in the country where you are taking it.

Power surges are very common in many countries and could damage the machine. Although many ultrasound machines have a built-in surge protector, having an extra external source is reasonable. Examples of simple surge protectors including the Belkin Surge Cub or GE cord with surge protector. These should be used each time the machine is plugged it, which may be difficult with portable machines, so smaller surge protectors are often more convenient. 

Unfortunately, many sites may not have access to electric outlets or do not have clinical space where a cord reaches or reliable power throughout the day. Extension cords can be helpful but may not always be practical as they will have to transverse an entire room often filled with other equipment or patient beds. A quick solution is to purchase an extra battery to swap out throughout the day. Battery life is variable, however, and often decays over time making this solution somewhat less than ideal. If using this method, make sure you consider the cost of an extra battery (or two) when budgeting.

Security

Keeping the ultrasound machine safe and secure is extremely important, this is especially relevant for cart-based and hand-held devices which are easiest to move. Several options exist, and it is always best to ask local colleagues for their insight into how best to keep the machine and equipment safe.

For many cart-based units such as the Sonosite M-turbo, the machine is readily removed from the stand leaving it vulnerable to ‘walking off.’ Probes are also detachable and may not be easy to secure overnight. If the machine is being donated or left at the site, you should strongly consider getting it insured by the local facility. Another fairly common option is to have the machine engraved, thus decreasing the temptation for theft (because it will be harder to re-sell).

Possible security solutions

Probably the easiest and most commonly used security solution is to lock the machine up in its own room or locker/cabinet. This has the advantage of being secure; however, it has the notable disadvantage of having the machine be less accessible- someone will have to go get the machine out every time to use it. One must also decide who has the keys to the room or locker and how easy it will be to find that ‘keeper of the keys’ when you want to scan. One solution may be to designate a person who is always on-sight (for instance the charge nurse or security guard) to hold the keys instead of a member of the medical team. Another solution is to use a lockbox with a code (possibly brought with you from home), so that keys are not needed.

Another solution to security is to lock the machine to a bar/wall. In many countries, large solid metal bars are used to secure important equipment. If this is available, you can bring a bike lock with you  from home and  just attach the machine to the metal bar or other solid structure. A quick note: if the cart easily separates from the machine, make sure you lock them both!

Storing the machine in a locker or room may be a good solution for overnight storage, but you may choose to have a more accessible location during the day such as in someone’s office or behind the nurse’s station. If there is a security guard in the building, consider using that building or room for overnight storage as it will be the most secure.

A final solution, especially for portable and hand-held devices is to take the machine home at night. This is obviously more difficult if the machine is large, bulky or attached to its cart. It may, however, be a good solution for short-term mission visits with hand-held devices. 

Customs and international transport

Some machines are so large they can only be shipped, either by DHS or a shipping container. Depending on where you are working, this may or may not be a secure option due to concerns of theft or mishandling. You should discuss with your local partners to determine the best strategy. Occasionally, there are agreements with other agencies and you can have your ultrasound machine loaded with other equipment in their shipping container. Another option would be to find an NGO that regularly receives shipments and to see if the machine could be shipped to them. 

In some cases, it may be possible to transport the machine by land. This could involve driving- or having it driven- to the location. Customs forms must still be completed at border crossing. This is obviously only practical for locations that are relatively closer and where it is safe to drive.

Transport by air is often the more secure and convenient option. Luckily, many handheld and portable machines can be carried on an airplane. It is best, if possible, to bring the machines as carry-on and not transported as checked luggage so it does not get lost or diverted. Ultrasound machines should go through security just like a tablet or computer without too much difficulty. Occasionally, you may be asked to check your hand-held luggage. If so, alert the flight crew and they may be able to make an exception for your special medical device or store it in a closet. Your luggage may also be at risk of getting wet, especially if you are outside transferring to a smaller plane which is very common at some international airports. Keeping the machine in a  garbage bag inside your suitcase is a simple way to try to keep it dry. If brining a larger cart or stand, it often can be broken down and may fit in large suitcase. When brining gel, you will likely need to check it, as it is consider a liquid.

Regardless of how you cross a border, you will encounter Customs. A letter from the facility or organization with which you work specifying that this is donated equipment is helpful if issues do arise on arrival at Customs. This same letter can be written from your home institution. See example customs letter.

Another useful document is the proof of sale for the equipment. This is helpful when you are leaving the country to prove the machine was not purchased (and thus not taxable) in the country you are visiting. 

Additional forms may also need to be filled out for the machine. Do not be surprise if the machine is carefully inspected at customs! Do not get upset, just be polite and respectful and present your documents and describe the machine’s intended use.

Servicing the machine

Inevitably, the ultrasound machine will have issues and will need to be serviced. This, unfortunately, will likely not be as simple as at your home institution and you may have to be creative- and patient!

Some countries or regions will have a local representative who you can contact to help out. This is true in South America and Europe, however, for most of Africa, the representative is far away and the machine may need to be taken abroad. You should consider the risk/benefit of mailing the machine versus transporting the machine in person. Although it may take more time to transport the machine in person, it may be a safer and more reliable option. Below are the lists of international contacts for a select number of companies:

CompanyWebsite
Sonositehttps://www.sonosite.com/contactus
Philipshttps://www.philips.com/c-w/country-selectorpage/global-country-selector.html
GEhttps://www.ge.com/directory
Mindrayhttps://www.mindray.com/en/global.html
Butterflyhttps://www.butterflynetwork.com/choose-your-country

Apart from machine representatives, local mechanics and technicians can be a viable solution. There may be a wealth of technical acumen at your international site, and it may end up being your best (or only) option for machine repair. Recognize that servicing a machine outside of the manufacturer typically voids the warranty and so proceed at your own risk; however, for a refurbished or older machine, this is likely already a moot point.

Take aways

  1. Plan in advance for how you will power, transport, store, secure and service the machine. 
  2. Consider differences in voltage/plugs and consider bringing an adaptor and surge protector and/or an extra battery
  3. Be aware that machines may need to be shipped/transported for servicing.
  4. Make sure you bring documentation for the machine and be patient and polite with all customs agents.

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