By Philippe Jeanty
Today we began the third training course at Central Women’s Hospital in Yangon, which is a national referral center for obstetrics and does more than 15,000 deliveries a year. We started the last course with the exact same participants as the first and second year in 2016 and 2017 who returned from all around the country. We were happy to see old friends again. Only one student was retained for military duties and could not attend. This exceptional consistency of the student body was great for the continuation of the education: no starting back at the basics.
After the chair woman of the hospital and the OB/GYN Dept made a welcome address, Philippe reminded the students that this was their last opportunity to ask questions and interact and that from now on they were supposed to become the teachers in their communities! Nothing like a tinge of fear to sharpen attention. Another message was that the course was covering the basics but that there was much more to learn and to make use of the resources that were available including the e-book from Alfred, the lectures on the ISUOG and TheFetus.net, as well as the material on the DVD provided by Mindray and Concordia.
The first presentation was about fetal echo to not only demonstrate the usual views, but also the worrisome signs and findings that should make them refer to specialist.
This was followed by talks on ectopic pregnancy and placental abnormalities by Dr. Federico Badano (Argentina), and a talk on the best uses of ultrasound on the Labor Ward by Dr. David Berck (US). After a short lunch, we spent the afternoon with live hands-on training with patients from the hospital’s outpatient clinic with ISUOG Outreach veteran Dr. Gwang Jun Kim from Incheon, South Korea For most of the patients, it was their first ultrasound of the pregnancy.
The scanning during the first afternoon demonstrated the disparate amount of practices with some good scanners and some that still needed hand holding. Initially we were going to use the OPUS trainer aside from the 5 ultrasound scanners, but it turned out too few had laptops and this was not practical. We therefore used the phantoms that we had used in Mongolia and Drs Khin Latt and Ei Swe Syn kindly made 3 phantoms.
A basic skill that seems difficult to acquire for several participants is how to align the transducer parallel to the long bone. Many seem to not rotate, translate and rock the transducer sufficiently and that frustrates them and slows the examination. Any who had trouble with the femur identification got send to practice in the phantom. Incidentally Jell-O is not available in Myanmar but they substitute with Agar (same stuff as in Petri dishes) which is apparently used locally for making desert, thus perfect replacement.
Federico very first case was an accreta in a primigravida with no uterine manipulation before pregnancy! Good pick-up of an unusual case. Another case was a trisomy 18 fetus with multiple findings including Dandy-Walker cyst, vermian hypoplasia, posterior callosal dysgenesis, bilateral cleft-lip and palate, unbalanced atrioventricular septal defect (Rastelli A), and double outlet right ventricle. The fetus also had overlapping 2 over 3rd finger and 5th over 4th. Gwan Jun and Fede demonstrated the findings which were good introduction for the next days lectures.
In the evening we had dinner in a restaurant featuring many typical regional dish.
During subsequent scanning sessions we adapted more the scanning to individual skills, some students still needed basic training, some interested in umbilical Doppler, others in myocardial performance index: a very broad range of skills! This group is remarkable in that they have great technical knowledge but not enough practical knowledge.
On the second day we also introduced ultrasound guided punctures and it was surprising to see not only the interest of everyone but also the skills. Some students who still struggle with a correct BPD could insert the needle in the cyst from our phantom with no problems. After the workshop, when there were no more patients everyone took a turn at doing needle guidance. This was not officially in the curriculum but probably should be added as it was very popular in Mongolia too. First they learned the simple mechanics of needle guidance: stay in the exact plane of the transducer, don’t move the needle sideways but always pull out change angle and then reinsert, giggle the needle… After they were familiar we reviewed tips related to maintaining a sterile procedure.
To limit the drudgery of listening to lectures for half a day we peppered then with questions, Gwan Jun and David being particularly skilled at that.
We also started a “recap” test by dividing the students in 2 groups each with a large sheet of paper and asking them to list everything that needs to be seen in a 4-chamber view, transcerebellar view, what are the criteria for secure diagnosis of ectopic pregnancy or miscarriage. This was very fun and challenging to get them to find every single item. Ultimately the teams were ex-equo!
So from the 7 courses i have attended i think what we can remember as techniques that were effective include:
-“Show and ask” cases to reinforce more theoretical lectures
-Ask small group (3-4 students) to go to the front of the class to demonstrate findings on an image. This works best then asking everyone, as most are too shy to answer from the classroom but once in front they manage. The groups are rotated for each cases.
-Positive reinforcement (chocolate gold medals) bring smile and friendly competition, plus a visible record of those who try.
-Phantoms should be the first stage of scanning to teach the mechanics of handling the transducer
We are very grateful for incredible support and hospitality by the staff of Mindray and Concordia especially Sherry Wu, Wai Thu Soe, and Justin Liu, NiTar and Chen Chen. They really went out of their ways to make everything run smooth. And being veterans they knew the system well and everything was there on time, the equipment running smoothly and supplies ever present. A real dream situation.
Like in Mongolia, my experience has been that successful training occur when strong local women are the organizers: this was very true here with a very dedicated staff. No waiting for patients, no chaos, a smooth efficient flow, and like last 2 years a large room we all shared for scanning making it easy to ask help around and show interesting images.
Something that I should have done better and we will improve in future courses is save the interesting images to show the next days to those who might have missed them.
We are looking forward to 2 more days of training!