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The Arusha Story

Where to start? Probably with the plane crash, I suppose.  Back in 2014, I was in Tanzania sitting with a group of doctors talking to Pat Patten at the Arusha Flying Medical Service base about his operation, when a call came in from the Maasai at Ngongonero that the clinic plane had crashed with five people on board. No more information. What could be better for an ED doc crazy for flying? Need help? Pick me! Pick me!

Off I went with Pat, who commandeered a Caravan from a friend, took out the seats and loaded our only stretcher and a bunch of IV fluid and off we flew. Here is what we found:

It was a Scoop and Fly scenario with us ending up in the Emergency Department of the Arusha Lutheran Medical Centre where we arrived to overwhelm them. Dr. Peter Mabula, then a junior doctor, was on shift and was happy for help. We liberated the X-ray department ultrasound machine, an old Sonosite Titan with a single curvilinear probe, cord alarmingly reinforced with tape and added bedside ultrasound to the assessment. Then I met Dr. Wendy Wilmore, a Canadian surgeon who had just two months previously arrived to develop a surgical residency program at the hospital and left the patients in her capable hands.

Cut to 2016, I’m working with AMREF Flying Doctors in Nairobi and across the bar at the East Africa Flying Club I spy none other than Pat Patten. “ Hi Pat, how are things in Arusha? How did those crash victims make out? Do you know if they ever got any training in bedside ultrasound at the hospital?” “Let me put you in touch with Wendy” he said.

Wendy was not really swept away by my offer to help with training! She acknowledged it was a big need but they had already had training from various visiting doctors and it simply wasn’t all that useful. “People come with a machine and show us neat things you can do with ultrasound. Then they leave, and nobody feels confident or competent enough to do it themselves”.   I countered, ”What I have in mind is less Show and Tell and more Pyramid Scheme Mathematics.” I gave her a brief history of how EDE and CPOCUS (then named CEUS) had successfully retrofitted emergency doctors in Canada with POCUS capability and before you could say FAST she was on board.

So how does this work? There are four pillars on which it is built, each essential to success.

1. Training that actually works, is world class and internationally recognized. These folks are trying to save lives often with diagnostic equipment that is either not there, not working, or the patient can’t afford to pay for it. When we can make them competent at basic POCUS applications it enormously increases their ability to function.
2. The CPOCUS community support. “The EDE course” makes the online basic course available free, CPOCUS waives fees for membership and certification of IP’s and EDE2 allows us to use their materials for advanced courses. No one in a resource-limited place could hope to be able to pay for all that.
3. “Bure ni Bure” is a Swahili proverb that translates as “ Free is Worthless”. This is not your average aid project (more like a holiday for workaholics) so there is no grant or funding of any kind. It also has to be able to last on its own when I have run out of add-on vacation ideas in East Africa. So participants are charged the local costs of putting on the course to pay for models, gel, water, paper towels soap etc. No exceptions, no excuses, no refunds.
4. “Pay-it Forward” Everyone who takes the course is told the value of the training they are getting in CAD. They then pay a realistic amount for the local costs and promise the rest in sweat equity as instructors. We put on an EDE course twice at each visit. If you take the first EDE 1 course, then bootcamp & CPOCUS exams in the first week, as a new IP you will be a bedside instructor at the second EDE course. You will be supported by experienced instructors and it really consolidates the knowledge and skills.  We then put on a one day EDE2 course or courses. You have to teach EDE1 to qualify to take EDE2. We start with the critical care modules only. In turn they must then teach that as a bedside instructor before they will be eligible for further EDE2 courses. And so it goes…

Where has all that got us? Well now after 4 visits we have 40 EDE 1 graduates, 20 IPs of whom, 15 have instructed at least one course/ bootcamp. 13 EDE2 critical care course graduates of whom 3 have further instructed at EDE2 and taken EDE2 diagnostic modules.

And Wendy complains the machine is never in ICU when she looks for it because someone is using it elsewhere! That old Sonosite Titan still has its curvilinear probe wrapped in tape but they now have a sector probe also for EDE 2 cardiac scanning and as a back up when the old tape job finally gives way.

Oh, and I hiked up Mt. Kenya, Mt Meru, Oldoinyo Lengai and Kili before I finally realized that all volcanoes have really steep sides and I should look for other vacation ideas.

So what’s next?

Excerpt from the EDEblog 2019