In low-resource settings, physicians may operate in an environment with limited information, limited resources, and under immense time pressure. With the scarcity of computed tomography (CT), plain films, magnetic resonance imaging (MRI), invasive monitoring, and advanced laboratory studies, the importance of point-of-care ultrasound (POCUS) exponentially rises. Lack of resources can be encountered in rural areas of high-income countries (HICs) as well as in the majority of the developing world, making POCUS a key to the practice of medicine. Advanced imaging methods such as CT or MRI are typically unavailable, or when present, inaccessible to the majority. These limitations include not only cost and maintenance of equipment, but also the training necessary for technicians and the need for interpretation of studies, which is usually done by another provider. All these factors result in an extreme scarcity of advanced imaging. For example, Haiti, a country of greater than 10 million inhabitants, currently has four CT scanners, all of which are located near the capital. These machines are often available for only a few hours of the day and are frequently not operational due to the need for repair.
POCUS allows providers to save hours and sometimes days in certain areas of the world where it is common for plain radiography to take 24 hours to be obtained and often requires that the patient go to another facility. There have been many cases of morbidity that was sustained during patient transport to obtain imaging studies.1
Although image acquisition and interpretation are key to POCUS, there are many more regulatory and logistics challenges that arise when implementing POCUS in a new setting.
In the same way that all travelers should learn as much as possible about a destination before the start of a trip, the visiting clinician needs to understand as much as possible about a host site prior to arrival. It is often overlooked that low- and middle-income countries (LMICs) have appropriate regulatory and governing bodies that preside over importation of equipment, immigration status licensure, and credentialing of providers. Many projects have failed to launch due to an ultrasound machine that is held in customs or a provider with the wrong visa class. Although many programs operate in an ethic and legal gray zone, local authorities’ ability to self-regulate must be anticipated and respected. A local partner is extremely helpful in navigating these challenges.
Having clearly defined project objectives prior to departure will help significantly in determining which obstacles you may face. A short medical trip where one will bring all necessary equipment and will be providing primary medical care is very different than attempting to implement POCUS in a new system. Meeting with local stakeholders, identifying the specific project goals in advance, and sticking to them will facilitate a successful trip.