Keefe, Devin

Medicine - Emergency Medicine

Residency

South Africa

My elective is a clinical rotation in the Emergency Department at Khayelitsha Hospital, a high acuity, large volume district hospital in Cape Town, South Africa. Khayelitsha is a teaching hospital affiliated with Stellenbosch University. My preceptor during the rotation will be Dr. Niel Van Hoving, an Emergency Physician and well-published expert in Point of Care Ultrasonography (POCUS). My overall goal is to gain clinical experience relevant to the local population with a focus on mastering bedside ultrasonography to diagnose severe illness and traumatic injuries. I am especially interested in POCUS applications in infectious disease and other novel indications. I will be collaborating with Dr. Van Hoving to collect patient data for a POCUS in TB screening project. I hope to establish a foundation for future research endeavors in LMICs as well as teach POCUS at Dr. Hansoti's East London clinical site in South Africa during a later elective.

Collaborating Institution: Khayelitsha Hospital

Point-of-care ultrasonography (PoCUS) is an emerging diagnostic tool in resource-limited settings.  PoCUS on the African continent, especially in low and middle-income countries (LMICs), remains underutilized due to inadequate funding for equipment and the lack of standardized training and credentialing. With my Paul S. Lietman Global Travel Grant, I traveled to the Western Cape region of South Africa to better understand how PoCUS was being taught and employed in an academic setting with an established, regionally relevant curriculum.  I completed a month-long clinical elective in the Emergency Department at Khayelitsha Hospital, a 240-bed district hospital outside Cape Town, South Africa. The ED treats approximately 4000 patients per month with a high incidence of trauma and high acuity infectious disease complaints. Khayelitsha is a teaching hospital affiliated with Stellenbosch University and the University of Cape Town Divisions of Emergency Medicine. 

    

Left: Teaching residents how to quantify right heart strain by echocardiographic measurements. Right: Hospital “Trolleys”: an open ED ward for continued management of stable patients

Having worked elsewhere in South Africa before, I arrived with a number of preconceptions about working in the region. On my first shift at Khayelitsha, after learning there was no CT in radiology and witnessing the heavy burden of trauma and disease, I realized that my expectations and clinical skills would be challenged. Practicing Emergency Medicine at Khayelitsha was a singular and transformative endeavor. My entire perspective on bedside ultrasound has shifted from an academic interest to a new appreciation of its power to diagnose occult disease and direct clinical management. Suddenly, my bedside ultrasound exams became definitive imaging in critically ill patients. There would be no confirmatory imaging studies outside of plain film radiographs. My technical skills and study interpretation had real influence on patient outcomes. My first positive trauma exam revealed a hemorrhagic cardiac tamponade. After a pericardiocentesis under ultrasound guidance, the patient became stable enough for transfer; narrowly avoiding impending arrest. More subtle findings challenged my abilities and confidence. The value of my training became evident; I am thankful for the high quality of our ultrasound curriculum and the teaching faculty at the Johns Hopkins Emergency Medicine Residency Program. I also discovered a passion for teaching junior residents at Khayelitsha through bedside demonstration and informal lectures.

The potential of PoCUS to reduce morbidity and mortality in overburdened, resource-limited medical systems is great. However, the challenges of creating, delivering, and maintaining the quality of a curriculum are complex. Salmon et al. describe a novel approach for ultrasound education on the African continent. The core competencies and credentialing in this model are based on local disease epidemiology and resources. The authors caution against the practice of adapting established PoCUS curriculum from resource-rich areas (Ann Emerg Med. 2017 Feb;69(2):218-226). My experience in South Africa supports the need for region-specific ultrasound curriculum.

I plan to collaborate with local stakeholders and return as a champion for PoCUS in South Africa. This experience has reaffirmed my career goal of becoming a leader in ultrasound education, especially in low-resource settings.  Over the next few years, I hope to promote the development of PoCUS curriculum in the region, institute ultrasound education initiatives, and quantitatively evaluate these initiatives using validated tools to measure provider competency.

Hospital entrance signage displaying prohibited items and statement that the Dept. of Health does not accept liability for any injury to persons

People

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs
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June 2019

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