Learning from Haiti.

In May, 2010, a 37-year-old woman, displaced from Port-au-Prince after the January earthquake, presented to Hopital St Therese in Hinche, Haiti, with a 2-year history of a slowly growing abdominal mass with associated dyspepsia, intermittent abdominal pain, anorexia, and weight loss. Her surgical history included four caesarean section deliveries and tubal ligation. Physical examination found her in no acute distress, with stable vital signs and a large, mobile abdominal mass extending to the subhepatic space. Haemoglobin was 106 g/L. A handwritten ultrasonography report from Port-au-Prince before the earthquake reported that she had a 10 cm mass with no further description, although on physical examination the mass was palpated at twice that size. No other laboratory or imaging capabilities were available. With no intensive care capabilities and limited transfusion supplies, local physicians had deferred surgery owing to diagnostic uncertainty. In July, 2010, a humanitarian surgical team brought a portable ultrasonography device to Hinche. Imaging of our patient showed a well-circumscribed, homogeneous, hypoechoic mass without invasion of adjacent structures (fi gure). The surgeons felt comfortable doing an exploratory laparotomy which revealed a well-demarcated, cystic ovarian mass, about 20 cm in diameter, resected via right oophorectomy (webappendix). Gross examination was consistent with a simple ovarian cyst. Diff erential diagnosis included ovarian and uterine tumours, pancreatic pseudocyst, and mesenteric cyst. She was discharged 2 days later with follow-up by local physicians. Our patient’s case demon strated the usefulness of portable devices in resource-limited settings. The well-circumscribed appearance of the mass and lack of invasion of adjacent structures provided enough supplementary information for surgeons to proceed safely at Hopital St Therese despite limited resources. Further delay in treatment would have resulted in persistent disability and possible torsion. In February, 2011, at last follow-up, she had had no complications. Diagnostic ultrasonography is a recognised, costeff ective aid for procedure-based care in under-resourced areas of the world. However, access to ultrasonography in these settings is limited. While we were in Haiti, ultrasonography also aided in the evaluation of soft-tissue masses, peritoneal disease, and uterine pathology. We recognise limitations of ultra sonography in these settings. Durability, weight, battery life, and ease of use all hindered our use of the device, but the greatest limitation of ultrasonography is cost. Although an aff ordable imaging modality, eff ective ultrasonography requires proper training, and the costs of both equipment and training can still exceed the budget for care of patients outside the industrialised world. Ideally, local physicians would be trained in diagnostic and therapeutic ultrasonographic techniques to allow for the continued benefi t of the local population. Although investment in both equipment and training would be needed, eff orts to implement programmes with portable ultrasonography in Tanzania and Rwanda have shown initial success, and we believe ultrasonography can play a vital role in resource-poor settings.