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Oby: From the campus of Harvard Medical School, this is Think Research a podcast devoted to the stories behind clinical research. I'm OBY.

Brendan: And I'm Brendan. And we are your hosts. Think Research is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center.

Oby: And by NCATS, the National Center for Advancing Translational Sciences.

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In the emergency department of Massachusetts General Hospital accessible technology is crucial to patients receiving care and to the physicians administering it as quickly as possible. When ultrasounds are needed in the emergency department, MGH utilizes point-of-care bedside testing. With this technology equal and equitable training and support is needed for all physicians. With her recently funded ultrasound project Dr. Eke is working to support female faculty of color in their various roles including training and mentorship. Dr. Eke is faculty and director of Global Ultrasound in the Department of Emergency at Massachusetts General Hospital.

Hello Dr. Eke. Thank you for joining us. We are super excited to have this conversation with you and appreciate you being here. We're going to get started and I'm going to pass it to my colleague Anna to begin.

Anna: Thanks OBY. I'm very excited to be here. So my first question, Dr. Eke you are the director of Global Ultrasound at Massachusetts General Hospital and then in that role you work with point-of-care ultrasound technology and education. So what is point-of-care ultrasound?

DR. ONYINYECHI EKE: Yeah. Thank you. And thank you so much OBY and Anna for having me this morning. So a point-of-care ultrasound is really the use of ultrasound technology at the bedside. In the setting that I am in at MGH it's in the emergency department. And we use point-of-care ultrasound to help diagnose and to manage out-patients that we see in the emergency department. The patients can range from pediatric patients to geriatric patients. It can range from patients that come in with a simple fracture to patients who are in cardiac arrest. So it helps us through that broad range to be able to facilitate care in the emergency room. It's also used in other settings. It's used in internal medicine, it's used in anesthesia, it's used in surgery, but for us here we use it in the emergency department.

Oby: So how does this improve care in emergency departments?

DR. ONYINYECHI EKE: Yeah, so because we are able to use this technology, this imaging modality, in the emergency room and by the patient's bedside, we are able to make kind of quick decisions. A good example is if the patient comes in during a trauma and we are concerned that maybe there is some blood in the abdomen. Instead of waiting to stabilize the patient, and take the patient to the radiology suite, call transportation, get everything all set, connect all of the tubes and all of the machinery, get everybody there plus the nursing staff, take them to the radiology suite, and bring them back which can take up to an hour and sometimes even more, three or four hours waiting for the results to come in. We're able to actually do this at a bedside. We're able to actually see blood in the abdomen and then make decisions based on that imaging and modality.

Now it doesn't always have to be a big event like a trauma or even a cardiac arrest. It can be, let's say for a patient that comes in with shortness of breath. What we want you to find out is the reason why they are short of breath. Because they have some fluid in their lungs or because they are having an asthma attack? Even if we do an X-ray the technician has to either come to the patient's bedside or again as I said, transportation has to take the patient there. With point-of-care ultrasound we can look at a patient's heart, we can look at the patient's lung, and we can decide if this shortness of breath is from let's say, fluid in the heart or a fluid in the lungs or if it's just because of an asthma attack. So this as you can see, because we don't have this second and third pathway where we have to get transportation and the technician and the radiologist to read the scans, we're able to do this all.

And ultimately, this helps us to number one, facilitate care. So we are expediting care. It helps us to manage the patients because we can have multiple-- we can do multiple studies for a single individual to see how they are responding to the management. And also help them in terms of the time they spend in the emergency room. It helps us to also get them either out of the emergency room or to a different floor because of everything that we're able to do. So at the end of the day, I think it's definitely a tool that we are using to, number one, improve a patient's care. But I think it's also a tool that helps us as physicians to be more efficient when we are delivering care.

Anna: How are physicians who aren't necessarily trained in radiology becoming familiar with this technology?

DR. ONYINYECHI EKE: Yeah, so physicians who are not trained in radiology like myself, emergency of physicians, for us actually it's part of our curriculum when we're undergoing residency training. So as part of our residency training, we get point-of-care ultrasound education. At least at MGH we have an ultrasound emergency faculty and what we do is we train the entire clinical care team. We train the residents, we train the medical students at Harvard Medical School, we train the attendings, and we also train the advanced care providers, which includes the physician assistants and the nurse practitioners.

Again, our focus is very focused. So we are only doing point-of-care ultrasounds. The radiologists on the other hand, are doing ultrasound that is not necessarily at the point of care, just generalized ultrasound, in addition to multiple other imaging modalities. For example X-ray, MRI, CT. So that we are not doing and for that and even for some parts of ultrasound we do need the radiologists. But for things that we can just do at the bedside to make a decision at the bedside and to expedite emergency care, all emergency of physicians who go through a residency training in the United States are exposed to point-of-care ultrasound.

And this is not just for emergency medicine anymore. Our internal medicine colleagues and our pediatric colleagues are also having this as part of their training. So it's not going to be surprising that in the next few years this might be part of the training for a lot of residency programs, not just emergency medicine.

Oby: That is amazing. So in your role at MGH you proposed a tele-ultrasound project that's recently been funded, so congratulations. Can you tell us more about this?

DR. ONYINYECHI EKE: Yeah so in addition to what I was saying about the education, as you can imagine, we have the points of care ultrasound faculty and we are all ultrasound trained. We have-- So after we finished our residency training we did a fellowship in emergency ultrasound, which is for one year. So we have this specialized training. Not everyone has that specialized training and because of that, we are in charge of training the rest of the clinical team. But as you can imagine, different people in the clinical team might need help at different times for which the ultrasound faculty is not always available in the department. So with this tele-ultrasound project we hope to bridge that gap in expertise at the point-of-care.

So let's say if there's somebody in the emergency department who wants to do a study, an ultrasound study. And let's say they are not particularly sure as to what they are finding or even how to obtain the image. With tele-ultrasound there will be a platform, so a platform by which you can communicate with an expert remotely. And then that expert would be able to guide that clinician in image interpretation, image acquisition, and also in the clinical integration. So that's what the project is hoping to achieve with this grant.

Anna: So it is important for this technology as well as the teaching element of it, to be accessible. Can you tell us a little bit about the global focus of your work.

DR. ONYINYECHI EKE: As ultrasound is growing in popularity and growing in use, everyone is seeing the use. In many I think communities outside of the United States-- I can just speak for example in sub-Saharan Africa, in West Africa where I am from. If you want to get an imaging study you have to pay first in the emergency department and then after you pay then you can get the study. With point-of-care ultrasound because we're able to do this at the bedside, it eliminates that element where you actually have to pay for the study before you can obtain the study. So you can imagine let's say you are in, somewhere in Lagos and you need a study to find out if this individual, let's say who was in a car accident, has blood in the abdomen. Now instead of the family members, who are already stressed out trying to find the money and the resources to pay for the imaging study, we can get the study at the bedside. And then figure out if this patient needs to go to the operating room or if we can do other things to kind of manage the care.

So that's the way the ultrasound is able to bridge that gap because there's limited resources. And even in the United States there's limited resources. If we're able to use this technology in those communities where there's limited resources then you eliminate this financial barrier for patients. And in the same way, it's helping us to facilitate a patient care here. It's who facilitates and it has been shown-- multiple studies have shown that it facilitates care in other communities that are resource limited as well.

Anna: In our initial conversation you had mentioned-- you were talking about resource limited institutions and in the way that it was being discussed you had said all institutions are resource limited to some extent. Can you talk about that?

DR. ONYINYECHI EKE: Yes. I think, we could just even look at where we are now. We are in 2021 in the middle of a global pandemic. I don't think there's a single place on this Earth that is not somehow strained. And so in this case now we're number one, we are still kind of living and fighting through the pandemic. Everybody is strained so anything that we can do to kind of relieve that strain. Let's say even if it is just having an imaging modality at the bedside where we don't have to have a radiology to come into the room and be exposed or take the patient to a radiology suite where they are going to expose other individuals. Even that small step can make a difference in clinical care and can even help make a difference in clinical morale. Everyone needs some kind of off system that can make a clinical delivery easier. And I think that point-of-care ultrasound is able to deliver in that aspect.

Oby: Also, can we circle back to the recently funded grant that you received. Was part of the grant that it was targeted towards these group of people and their ideas? By this group of people, I mean minority faculty and women of color.

DR. ONYINYECHI EKE: Yes. Thank you for the question. So the Center for Diversity and Inclusion at MGH has this grant, the Commission Teacher Grant. And they have also another grant for research scientists where they support minority faculty. And the goal of this grant is to enable minority faculty to focus on research. And we do that by getting grant money which is number one, able to buy down the clinical time. We're also able to afford us the opportunity to have research assistants or research resources, enabled to do our research. For me, part of the grant is going to be paying for some classes I'm going to be taking at the School of Public Health. Just so that I can get those research skills to be able to perform research that is of high quality.

So the grant has been around for a very long, long, time and has supported the careers of multiple minority faculty men and women. And so I am so glad and very fortunate to be one of the recipients of the Clinician Teacher Award this year.

Anna: I was wondering if you could talk a little bit about how the grant leads to sort of supporting women of color in leadership positions, mentorship, and maybe some advice you could give for individuals as to how to promote mentorship opportunities and allowing minority groups to feel like they belong where they are.

DR. ONYINYECHI EKE: Yeah. Thank you for the question. You know this grant is very important because again, it gives us that freedom to be able to do research and get the support for it. And at this institution research, in addition to clinical care and education, is how we is how we all grow and how we learn to take better care of our patients. I think for minority faculty, particularly for women of color, grants like this help to retain us. Because it's one thing to recruit a minority faculty into some institution like this one, it's another thing to say the work that you are doing is valuable.

So I think when we have grants like this, because grants like this mean that you have written up a proposal and that you have a mentorship team. And when you have a grant that has been accepted, then that mentorship team is there to support you. They have committed to supporting your career. And it's not just the mentorship thing but your department now. So it's not just the people on my mentorship team because I had to also ask my chair, who is so supportive, and other individuals to write me letters of recommendation. So when you have people who are supporting you within your department and outside your department, that goes to show that the institution is committed to keeping you. And I think that is one of the things that really supports minority faculty, particularly women of color, in addition to retaining us and also to recruiting us.

As I said, mentorship is also important but sponsorship and making sure that we are being called to take on leadership opportunities and to advocate for the work that we are doing in places that are going to kind of elevate us. I think that's also important. And so at the end of the day, I think-- and doing anything that makes us feel like number one, we belong. Not just us, but everybody wants to feel like they belong. Everybody wants to feel like they are valued. But I think for minorities, particularly for minority women of color, that is particularly important because historically we have been marginalized. So any opportunity that kind of brings us together, that values us, that lifts us up in the name of retention, in the name of recruitment, in the name of sponsorship, in the name of mentorship, all of those opportunities are very important. And so for that I thank this grant, I thank the Center for Diversity and Inclusion at MGH equal opportunity. I thank my department, my mentors, and all my sponsors for number one, making me feel like I belong here and for showing me that the work that I am doing and the work that I want to do is valuable. And I think every single woman of color wants the same exact things.

Oby: I wanted to circle back to what you were talking about-- basically how the technology can be used in different places and maybe the different-- honestly the different spaces you can use it in. And the different-- whether that's geographical, whether that is different situations in the ER, or the ED sorry. Where do you see it going from here? What are your future big plans for this work? I think you've spoken about some of it. I mean, I'm super passionate about West Africa and the work being done there and thinking about different communities like that who are, I love what you were saying about everyone's a bit under-resourced right now. But I think there's definitely areas where under-resourced is an understatement. But how do you see it kind of evolving?

DR. ONYINYECHI EKE: Yeah so I think with the pilot study that we are having in the MGHED with tele-ultrasound I think that's going to be a huge stepping stone to figure out if this actually works in this context. And as you said, every context is different. And if it works here the goal will be to also pilot this in other communities outside of the United States. So that's the big goal. One of the other big goals I have is just to continue to expand ultrasound, point-of-care ultrasound education and training in resource limited settings. One of the partners we have is an emergency medicine program in Kumasi, Ghana. And we've been able to have several of their residents join us for conferences, particularly for ultrasound conferences. And we've been able to actually have didactic lectures where these are residents and these are clinicians who are in Kumasi and they are able to use ultrasound and we can teach and they can actually use what we are saying to actually direct a patient care at their own institutions.

So the goal is to be able to do this for multiple communities because emergency medicine is still in its infancy, particularly in sub-Saharan Africa. In West Africa alone there's only one emergency medicine program. And there's a few in South Africa and East and Central Africa. So as more programs pop up, and even the programs that are already in existence, there is a need to strengthen this point-of-care ultrasound education. And that's where we step in. We have the expertise, we have the knowledge, all we need to do is just be able to transfer this knowledge to other individuals that wants to actually learn. So that is the goal. I'm really excited about what we are doing with Kumasi. We have some other partners in Uganda and also in India. So we are looking forward to continuing to give this knowledge and hopefully to be able to actually train individuals as well, at the bedside.

Recently we had a virtual kind of ultrasound didactic course. It was a two day course, we had over 800 registered participants. And each day, they were like about 200 or so, over 200 or so, people who had attended. And they came from everywhere. There were people from Lagos, from Costa Rica, from Lebanon, somehow it got through WhatsApp and everybody was there. And the enthusiasm was great. And that's just a marker for us that there is a hunger, there is a need. People want to learn how to use this by the bedside because they see the value, just as we see the value as well.

Oby: I actually have another question that kind of came up from that. The question I have is about cost. And that is cost to the individual and then cost to the hospital itself. It strikes me that part of why this may be so interesting and compelling to other groups is the cost associated with it. Can you speak to that at all? I know that's a very large question when you think about how health care works in America versus other countries versus how we use it. But I was just curious about that element. Even thinking about what I'm envisioning you're talking about the size of the machine and different things like that. It seems like there may be lower costs, which may seem advantageous to other people.

DR. ONYINYECHI EKE: Yes, you are you are right. There is lower cost in terms of the point-of-care ultrasound that we are able to actually do compared to with the radiology ultrasounds. So let's just go back to, let's say, the machine itself. Now the machines have transformed from the machines that maybe used to be used like 10 or 15 years ago. Now we have touch screens, we have very sleek machines that are not cumbersome and can go into the patient's rooms. And we also have machines that are literally the size of your hand that you can attach to your iPhone or maybe to an iPad. So the machines have really grown and of course the smaller ones are actually less expensive. And those are actually the ones that I use mostly in resource limited settings outside of the United States.

So because it's cheaper, that I think draws that appeal. This is something that institutions that are resource limited can actually afford. And I think again because we see the utility institutions outside of the United States have kind of committed to this. I mean a lot of institutions either have one or maybe two hand-held ultrasound machines and that is what their clinicians use at the bedside. I know that a lot of the companies now have definitely innovated and changed things. And they even have-- some other companies have subsidies. So let's say they may rent a machine or borrow a machine to an institution for a reduced cost depending on how resource limited that institution is. So compared to the big scans that you have to pay for in the radiology suite, this is definitely cheaper.

And I just want to say, it's not like we are replacing the radiologists. We are not. And I think I want to make that clear. We are complementary to the radiologists. For example, if there is a scan that we do by the bedside that is not completely clear then we will need the radiologists to do a more comprehensive scan. Or if there is a scan that we do at the bedside that saw some initial pathology, so sometimes we do need the radiologists to give us a complete scan. All of the x-rays, broken bones, if you think about what's going on in Haiti now, just reading a lot of the reports, they have actual x-rays. They need x-rays because of all of the trauma that has been going on. And I also think that they may also need some point-of-care ultrasound. So again, we work in complementary roles with our radiology colleagues.

Oby: That's a great distinction. Thank you.

Anna: Great. Thank you so much. I think we can all agree that it's really impressive and just to see the worldwide impact that this technology has and has the potential to have in the future. So thank you so much for joining us today. Thank you OBY for inviting me to be here as well. Yeah, Thank you.

DR. ONYINYECHI EKE: Thank you.

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Brendan: Thank you for listening. If you've enjoyed this podcast, please rate us on iTunes and help us spread the word about the amazing research taking place across the Harvard community.

Oby: To learn more about the guests on this episode, visit our website catalyst.harvard.edu/thinkresearch.