GUSI’s Role in Advancing POCUS Education

The Global Ultrasound Institute (GUSI) offers a range of educational resources tailored to equip healthcare providers with POCUS skills, including:

• FASH Module: Part of the Essentials Course, this module provides in-depth training on the FASH protocol.
  
• Fellowship Programs: Designed for individuals aiming to become POCUS champions or train others in ultrasound techniques.
  
• In-Person Courses: Hands-on training sessions for those who prefer experiential learning.

By Marcela Osorio, MS4

This blog post, authored by Marcela Osorio, MS4, delves into the critical role of the Focused Assessment with Sonography for HIV-associated Tuberculosis (FASH) exam in diagnosing extrapulmonary tuberculosis (EPTB) among people living with HIV (PLHIV). Drawing from a qualitative study conducted in collaboration with the Global Ultrasound Institute (GUSI), Marcela shares firsthand accounts from frontline healthcare providers in Lesotho, Zambia, and Malawi. These narratives highlight the challenges and triumphs of implementing the FASH protocol in resource-limited settings, emphasizing its impact on patient care and the ongoing fight against HIV/TB co-infection.

Introduction

In regions burdened by high rates of HIV and tuberculosis (TB), timely and accurate diagnosis of extrapulmonary TB (EPTB) remains a significant challenge. The Focused Assessment with Sonography for HIV-associated Tuberculosis (FASH) protocol emerges as a vital point-of-care ultrasound (POCUS) tool, enabling healthcare providers to detect EPTB manifestations swiftly and affordably. Developed in 2010, FASH is tailored for resource-limited settings, offering a rapid bedside assessment to identify sonographic signs indicative of EPTB in people living with HIV (PLHIV) .ScienceDirect

This article delves into the experiences of frontline providers in Lesotho, Zambia, and Malawi who have integrated FASH into their clinical practice after engaging with the Global Ultrasound Institute’s (GUSI) training modules. Their insights underscore the protocol’s impact on patient care and highlight the ongoing challenges in implementing POCUS in resource-constrained environments.

The Focused Assessment with Sonography for HIV-associated Tuberculosis (FASH) exam is a rapid and affordable point-of-care ultrasound (POCUS) protocol used specifically in patients living with human immunodeficiency virus (PLHIV) to diagnose extrapulmonary tuberculosis (EPTB) — a disease often difficult to diagnose given its non-specific symptoms and paucibacillary nature. In light of the recent uncertainty in global access to tuberculosis (TB) and HIV treatment, along with recent reports noting an increase in EPTB incidence1-4, I partnered with GUSI to conduct a qualitative study exploring how frontline providers who had watched GUSI’s FASH module were using the FASH exam in their fight against HIV/TB. In today’s climate, hearing these perspectives is critical, especially for those of us removed from these clinical realities. Here is what I learned from providers in Lesotho, Zambia, and Malawi.

Setting the Scene

The providers who were interviewed (n=4) largely specialized in Family Medicine and  practiced in semi-rural settings. Three participants had never received FASH training prior to GUSI training; one was already a POCUS expert. All identified HIV/TB co-infection as a major contributor to hospitalization in their communities. In their general care for PLHIV, they described patients’ extreme poverty and community stigma towards HIV as significant barriers to care. Interestingly, one also noted that TB had become stigmatized because of its association with HIV.

“There’s still a lot of stigma around that [tuberculosis] as well. So people get quite scared of ‘if I’m coughing for more than a week or two, oh no, then maybe that’s TB…oh, I need to check for HIV to make sure I’m not infected’, and it becomes a fracas of almost like a circus when they’re trying to get hold to understand that anyone can contract it…”

In caring for patients with HIV/TB co-infection, providers identified limited diagnostic equipment for pulmonary TB and EPTB (e.g. Gene Xpert, Urine LAM, CT Scan, MRI) as another key challenge. Participants noted that sometimes chest X-Ray (CXR) is the only tool available in trying to diagnose disseminated or EPTB, which is not appropriate. Sometimes, the challenges compound, with even the CXR machine becoming unavailable.

 

FASH Favorites

As they tackle some of these impossible challenges, our participants all believed FASH to be a very valuable tool, both for the diagnosis of EPTB in PLHIV, and as a way to bypass these hurdles to quality care. One provider stated that FASH helped her bypass some of her patients’ financial limitations.

“…some patients do not – well, most patients, not some – do not have the financial capacity to be able to afford CT scans. But one thing that has helped is the POCUS, because we are able to scan…”

Others also noted that the FASH exam not only helped them establish a diagnosis and subsequent treatment in less time, but also built their confidence in their EPTB diagnosis when other tests come back with indeterminate or negative results.

“I think it’s a brilliant tool…it ends up lessening the time to get to correct treatment…if it wasn’t there, I think it would take longer…7 days or 14 days for results and you still have a patient in the ward waiting for the results to get the correct regiment of treatment for them to get better. But with this we are able to, not exactly blindly, but in some way get the correct treatment for them to have.”

“…if I’m dealing with a patient that we think has severe HIV disease, and we highly suspect that maybe they may have disseminated TB, then FASH is one of the things that you do…So, if the rest of the investigations are negative and maybe only FASH was able to pick, for example, pericardial effusion, and you insist the patient to get treated for TB and they improved, then your confidence obviously goes up.”

Overall, our participants all felt that healthcare workers in areas with high prevalence of HIV/TB can greatly benefit from using the FASH protocol to diagnose EPTB, and can even easily teach other colleagues to do the same.

“It’s very, very useful in this setting…it’s a simple protocol and it’s easy to follow and easy to teach, and provides excellent diagnostic information”

Implementing FASH: Opportunities and Obstacles

Although providers were eager to use the FASH protocol, they also identified obstacles to implementing it in their practice.

Overwhelmingly, providers felt that the lack of POCUS equipment and consumables hinder their FASH use. Many stated that there are less than a handful of butterflies, or only one ultrasound machine, for the entire hospital. One shared that sometimes a colleague may take the POCUS bag home by mistake, which means they are unable to access that tool for the entire day. Another shared that sometimes the equipment is there, however there simply is not enough gel to obtain an accurate picture. Interestingly, one provider shared that this lack of equipment not only delays care, but also makes it harder for workers to practice on an individual basis to improve their skill.

”I think we have 3 butterflies for the program. So, we use them when we are during rotation. That’s how it’s a bit limited for me to actually practice on my own…some challenges with FASH is that if you’re not updating yourself or practicing more, getting the correct depth, or gain, or the right picture can be a challenge individually to get to the right diagnosis…”

Another frequently mentioned challenge was the lack of knowledge and confidence in FASH among colleagues. Sometimes, there simply are not enough providers trained in how to conduct the FASH exam for the amount of patients who could benefit. Other times, consultants are mistrusting of the accuracy of a bedside FASH exam, despite it being evidence-based.

“…I think it’s still being slowly accepted into the community of doctors. Some would rather have a radiologist give you the results and the scans than for them to look at a live POCUS scan that you would do…”

Lastly, this lack of knowledge in the FASH exam results in unmet mentorship needs for those on the frontlines eager to improve their FASH skills.

“…whatever I do for a patient today, I should be able to discuss that with someone with more experience or similar experience…maybe they can look at it in a different way, and you know, help each other to learn…if possible, to create a forum where people can share their experiences, like hands-on experiences, patient stories, and what they have done, what they found, what lessons they can get from the technique to finding pathologies and making decisions towards my patient. That will affect my…capabilities or my competence.”

Conclusion

Although our sample was small (n=4), the insights were clear: HIV/TB and HIV/EPTB co-infection remains a critical threat in resource-limited settings, and providers are eager to use tools like FASH. However, they need better access to devices, consumables, training, and longitudinal mentorship.

I would be remiss if I concluded this report without mentioning the recent changes to the United States President’s Emergency Plan for AIDS Relief (PEPFAR). Three providers noted that recent PEPFAR policy shifts have disrupted their patient care. Below are excerpts of their testimonies.

“Like today, we have just received the news that one of the medicines we use in the management of HIV is out of stock. That rings a bell a lot, because it means procurement and everything has been affected. So, as Malawi, we haven’t been spared. We are affected as well.”

“…some of the direct impact that I’ve heard already has been: PEPFAR would be the supplier of the fuel and vehicles to transport people to the referral hospital. Now that the people working for them are no longer, and the program is not going on, that is no longer happening.”

“I had a few colleagues who were under the PEPFAR, not just here in Zambia, but in other countries, where that aid was cut down. As an implementation going forward, they haven’t said anything, they’ve just given people leaves of absence.”

Reflections

As I listened to the stories of providers fighting the non-stop fight against HIV/TB, the word that kept echoing in my mind was “privilege” — the privilege that comes with being a trainee in the United States with great access to HIV and TB treatment. Privilege opens the door of selective amnesia and invites us to walk in. It entices us to forget about the problems that do not apply to us and absolve ourselves of responsibility. As we all grapple with the current unprecedented, violent disengagement in global health and global health research, and as we ask ourselves how we can help in our global health partnership, we must recognize our privilege, and how it beckons our responsibility. HIV, TB, and EPTB, along with the defunding of their care, demand expanded access to diagnostic tools like POCUS and FASH. As POCUS advocates, how can we improve access to POCUS devices and supplies abroad? How can we support sustained mentorship for colleagues on the frontlines?

As a start, I would encourage you to interview your own global health colleagues and ask them what they need from you right now. For those of you committed to tackling the deep inequalities inherent within the field of global health, I would encourage you to read Dr. Madhupar Pai’s recent article,

“Shifting power in global health will require leadership by the Global South and allyship by the Global North”, published in The Lancet, where he offers tangible steps, big and small, to do so.

To conclude, I will leave you with the words of one of the providers that impacted me the most as he reflected on the FASH exam:

“I think it’s a beautiful tool. Even as it is, I can’t think of anything I would wish to add, except probably to start thinking of what ways we can make it more available, more accessible for us in a resource-limited environment. I don’t know how that can be. I can’t even hazard a guess. But I know we need it a lot…Think of ways to help us in the resource-limited environments, even if it’s payments, or installments, or things like that, because it’s quite frustrating to get such great training and then you’re so limited in applying what you’ve been trained on because you don’t have access to the equipment…”

Acknowledgements: Special thanks to the providers who gave of their precious time to share their stories and experiences; to my mentor and research advisor Dr. Daria Szkwarko; to the Global Ultrasound Institute team, namely Dr. Kevin Bergman, Dr. Mena Ramos, Jahheart Rabina, and the rest of the GUSI Informatics team; and to Dr. Tom Heller. This research was supported by the National Institutes of Health (NIH): National Institute of Allergy and Infectious Disease (2R25AI140490).

 

Marcela Osorio
MD Candidate
The Warren Alpert Medical School at Brown University

 

 

 

References

1 Rolo M, González-Blanco B, Reyes CA, Rosillo N, López-Roa P. Epidemiology and factors associated with Extra-pulmonary tuberculosis in a Low-prevalence area. J Clin Tuberc Other Mycobact Dis. 2023;32:100377. doi:10.1016/j.jctube.2023.100377

2 Oda G, Lucero-Obusan C, Schirmer P, Chung J, Holodniy M. Risk Factors for Extrapulmonary Tuberculosis Among US Veterans, 1990-2022. Open Forum Infect Dis. 2024;11(12):ofae698. doi:10.1093/ofid/ofae698

3 Brehm TT, Terhalle E. [Extrapulmonary tuberculosis]. Dtsch Med Wochenschr. 2023;148(19):1242-1249. doi:10.1055/a-1937-8186

4 Li T, Yan X, Du X, et al. Extrapulmonary tuberculosis in China: a national survey. Int J Infect Dis. 2023;128:69-77. doi:10.1016/j.ijid.2022.12.005

Quick Takeaways

• The FASH protocol is a valuable POCUS tool for diagnosing EPTB in PLHIV, especially in resource-limited settings.
  
  
• Clinicians report improved diagnostic confidence and expedited treatment decisions after implementing FASH.
  
  
• Challenges such as equipment shortages and training gaps hinder widespread adoption.
  
  
• GUSI provides specialized training modules, fellowships, and in-person courses to support POCUS education.
  
  
• Visual aids and structured protocols enhance understanding and application of FASH in clinical practice.
  
  

Conclusion

The integration of the FASH protocol into clinical practice has demonstrated significant benefits in diagnosing extrapulmonary tuberculosis among people living with HIV. By enabling rapid, bedside assessments, FASH empowers healthcare providers to make timely and informed treatment decisions, particularly in settings where advanced diagnostic tools are scarce.

However, to maximize the protocol’s impact, it is essential to address the challenges hindering its widespread adoption. Investments in equipment, comprehensive training, and ongoing mentorship are critical components in this endeavor. Organizations like the Global Ultrasound Institute play a pivotal role in advancing POCUS education, offering tailored resources that equip clinicians with the necessary skills to implement FASH effectively.

As we continue to confront the dual epidemics of HIV and tuberculosis, tools like the FASH protocol represent a beacon of hope, bridging diagnostic gaps and enhancing patient care in the most vulnerable communities.

Frequently Asked Questions (FAQs)

Q1: What is the FASH protocol?

A: The Focused Assessment with Sonography for HIV-associated Tuberculosis (FASH) is a point-of-care ultrasound protocol designed to detect sonographic signs of extrapulmonary tuberculosis in people living with HIV.BMJ Open

Q2: How does FASH benefit clinical practice in resource-limited settings?

A: FASH enables rapid, bedside assessments, allowing for timely diagnosis and treatment decisions without reliance on advanced imaging technologies.

Q3: What training resources are available for learning the FASH protocol?

A: The Global Ultrasound Institute offers comprehensive training modules, fellowships, and in-person courses focused on POCUS and the FASH protocol.

Q4: What challenges might clinicians face when implementing FASH?

A: Common challenges include limited access to ultrasound equipment, shortages of consumables like gel, and a lack of trained personnel or mentorship opportunities.

Q5: Can FASH be used in patients without HIV?

A: While FASH is specifically designed for PLHIV, some of its components may be applicable in broader contexts. However, its diagnostic accuracy is most validated in HIV-positive populations.

For more information on the FASH Exam, please visit GUSI’s FASH Module, found under the Essentials Course’s “GUSI Additional Topics” section, along with the protocol published in The Ultrasound Journal.

If you need further assistance or additional edits, feel free to ask!

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