Global Health Radiology

Welcome Radiology Volunteers

This page features resources for onboarding radiologists for serving in low-middle income countries or resourced-limited settings utilizing teleradiology platforms or on-site. This has been created for the volunteers serving at Tenwek and Diospi-Suyana hospitals, and some of the information is specific to that group. However, much of this information will be helpful for those looking to explore Global Health service.

On-boarding: clinical

Educational case collections

I have saved and uploaded several cases from Tenwek and Diospi Suyana hospital which highlight some of the advanced and unique diagnoses you will encounter there. You can click on the photos or links to review the collections.

As a Western-trained radiologist, there are a few things that are helpful to keep in mind:

  1. Patients present later and with more advanced disease than typical for the US, and may have uncommon diagnoses. They require a different mental paradigm and an open mind when reviewing their scans.

  2. Patients may have misleading or incomplete histories.

  3. You must familiarize yourself with tuberculosis, hydatid disease, and ascariasis, which may be endemic in low and middle-income countries but are rarely seen in the US.

  4. Radiology plays a huge role in directing patient care, and in some ways is asked: "more questions" than typical in the US. Many laboratory studies we take for granted are not feasible or take weeks to get back. Pathology can take months. MRI is often not available. Keep your focus on helping direct the treatment team toward the next best step for the patient (clinical evaluation, follow-up, surgery, biopsy, etc).

  5. Ask for help: these cases can be much harder than anything you typically encounter in your workday. This can be related to suboptimal scan quality, atypical and complicated appearance due to delayed diagnosis, or unusual/uncommon pathology. Go the extra mile, as taking the time to ask for a second opinion and research can make an enormous difference in outcomes.

  6. Be practical and action-oriented in your reporting of the impression: think about how your report will direct the treatment team, and help steer them in the right direction. Give a complete differential diagnosis, favored diagnosis, and recommendations for the next steps.

Comprehensive review of Tuberculosis

Dr. Read Vaughn, MD

Pulmonary Tuberculosis - Kanne.pdf

Imaging of Pulmonary Tuberculosis

Dr. Jeffrey Kanne, MD

Abdominopelvic TB cases

Key features:

  • low attenuation adenopathy

  • peritonitis and ascites

  • pott disease (+ subligamentous spread with cold abscesses decompressing into muscles)

  • less common but think about when you see liver/spleen lesions, mycotic aneurysms, unexplained masses (often cystic-appearing) without a clear explanation

  • ddx can include lymphoma, sarcoid, other disseminated infection, carcinomatosis

Hydatid disease cases

Key features:

  • Liver > Spleen > Lungs (tapeworm infection through GI tract into portal system)

  • Complex cysts with daughter cysts; cysts calcify and become smaller after rupture

  • floating lily/membrane after cyst rupture

  • spread throughout the peritoneal cavity after liver/spleen cyst rupture (e.g. you should see liver/spleen disease if you see peritoneal disease)

  • ddx is usually limited when you are familiar with this

Ascariasis cases

Key features:

  • tubular, elongated filling defects in the small bowel

  • "drink" oral contrast, bright center

  • large burden can obstruct when treated

  • may be incidental

  • can involve other systems (lungs, GU)

Arrow injuries cases

Tribal fighting can lead to new patterns of injuries that you have never encountered on CT before.

On-boarding: non-clinical

Tenwek Hospital Profile.pdf

Hospital background

Please review this wonderful document prepared by Dr. Tim DeKoninck, Head of Critical Care Services/Department of Accident and Emergency at Tenwek Hospital.

Internal/external consultations

We have created a central email where radiologists or physicians can reach out to us for questions about an examination. You will often hear back from someone in our group the same day (<24 hrs).

These cases are often some of the most challenging and complex cases you have encountered as a radiologist. There may be motion or suboptimal use of contrast, making it even more difficult.

Please use this internal consult service whenever you encounter a challenging or unknown case and you'd like a colleague or expert (subspecialized) opinion. Because these are often very tough cases, have a low threshold for asking for a second set of eyes.

This little bit of extra time and effort will often make an enormous difference in the outcomes for the patient and help the clinical/surgical team provide optimal care.

CT reporting templates

This folder will take you to our library of suggested structured reporting templates (optional, and modifiable based on your preferences).

After creating a report, save it as a PDF and upload it to the teleradiology platform (Nucleus).

UPDATED Tenwek CT ordering and contrast guidelines.docx

CT ordering Guide

Here is the ordering guide which details the CT examinations and indications offered at Tenwek Hospital.

Additional resources/information

Radiology in Global Health texbook

This is a wonderful, comprehesive review of Global Health Radiology for those looking to expand their understanding and impact in the world.

Suggestion: those with institutional/university library access to Springer may find this book in PDF form.

The Dawn of Training Programs in Africa

Dr. Frank Minja and co-authors have written this excellent overview of the current status of training programs in Africa.

Peer review and feedback model

Peer review and support are essential to practice and quality improvement.

While admittedly painful, feedback is essential to targeting areas to grow in our image review, knowledge and reporting.

Even in a volunteering context, opportunities for peer learning arise when pathology or surgical confirmation of cases is obtained. Participating in virtual tumor boards creates a constant stream of feedback.

Feedback can be formalized and depersonalized to keep the emphasis on the learning opportunities, and shared with the group in a sensitive manner on a regular basis. Review of cases can be facilitated by sending out a written list or recording and sharing a short video simulating a case conference.

Here is a suggested information to send out.

  • Patient information:

  • Original impression:

  • Pathologic/clinical/surgical outcome:

  • Opportunities for learning or improvement:

Supporting tumor boards

Volunteers can support institutional tumor boards remotely, which creates bridges of institutional knowledge and pooled expertise. It can create opportunities to expand the pool of involvement to various departments and specialties as relationships are built across the institutions.

Due to differences in time zones, tumor board image reviews and comments can be pre-recorded and shared with the group instead of participating live. The cases should be sent out with 3-4 days' advanced notice so the radiologist has a chance to review the cases and pre-record (if applicable).

An example intake form can be viewed here.

Medical supply donations

MAP and Ethicon have wonderful, generous options for traveling with medical donations. Be sure to check out their offerings and contact the teams you are supporting. I simply shared the Ethicon order form with our surgeons and asked them to indicate which items they found the most useful.

https://www.map.org/ethicon

The website is somewhat confusing to navigate. First, you must complete the eligibility application (apply to the program). After application, you can submit your Ethicon order. I did not get a confirmation from them, but I did reach out and they said I could submit my order right after sending in my application. They reach out before shipment for the $65 shipping charge.

RAD-AID Country Reports

Free PDF reports created by RAD-AID highlighting the current state of radiology in a variety of LIMCs.