Patricia A. Pellikka, MD, FASE

As many of you know, ASE’s second medical mission camp in India wrapped up right before the holidays, and our volunteers returned home tired and fulfilled after this extraordinary effort. Seven onsite sonographers, 11 remote educators, 3 industry partners, 17 physician trainees, and 61 ASE physician members who assisted from their offices collaborated to provide limited echocardiograms to 1,096 patients under unique and challenging conditions. This type of partnership with fellow practitioners overseas is one of the most substantive and meaningful ways ASE works to promote quality of care all around the world, and I could not be more proud of our outcomes.

The feasibility of using focused echocardiograms and cloud computing to provide cardiac evaluation to a large number of people in a remote area, as documented at ASE’s first mission camp in January 2012, is published in this issue of JASE . This was a landmark event for ASE and has established a precedent for what we hope will be many more global collaborations. It required the vision and leadership of ASE member, Dr. Partho Sengupta, who has close family ties to India and recognized the value and importance of the opportunity. As nicely stated by Partho, this event “engaged physicians, sonographers, and engineers across the globe at once for many different reasons—humanitarian, cultural, and educational exchange, global health research, new technology evaluation, and patient care applications.”

For our mission work to have an even greater impact, we recognized that in new and innovative ways we must work to develop the image acquisition and interpretation skills of local practitioners. Thus, this most recent medical mission focused on teaching and improving the imaging skills of Indian physicians. Unlike in the U.S., where we can rely on well-trained sonographers to perform excellent echocardiographic examinations, Indian sonographers are few and far between. The hosts for this event, Medanta-The Medicity, therefore identified a need for Indian physicians to have additional guidance in maintaining quality and standards in cardiac ultrasound imaging. Determining how and when to fit this type of continuing education opportunity in around bustling clinical practices can be a challenge, so ASE and its industry partners stepped in to provide a brief but extremely intense hands-on experience for this community of practitioners.

Training at this mission was administered in two different ways: Initially, our team of seven ASE sonographer volunteers spent a day teaching participants at the Medanta hospital how to scan patients, providing these physicians with the tools they would need throughout the rest of this 5 day experience. This phase of the training included an innovative session called VISION, or Value of Interactive Scanning for Improving Outcomes of New Learners. Here, two echo labs were set up, each containing five beds. In one lab, ASE sonographers used GE Vscans for to provide onsite, face-to-face focused echo training to their Indian counterparts. In the other lab, a more futuristic arrangement was being tested: 5 echo machines (GE or Vivid I or Q) were connected to the Web using StatVideo EchoBoxes, allowing 10 sonographers in the U.S. to provide remote training to their Indian pupils. Both arrangements were spectacularly successful, and over 150 echos were performed over the course of seven intense hours of scanning.

Following this initial preparation, the 17 local physicians and their sonographer instructors traveled to a cataract camp organized at Dera Sacha Sauda, a spiritual institution in Sirsa, Haryana in North India. Here, the sonographers supervised as these physicians put their new skills into clinical practice. Patients who were recommended to undergo cataract surgery underwent pre-anesthetic evaluation and focused ultrasound examinations at the hands of the new physician trainees and their sonographer teachers. The focused echocardiograms were then uploaded to Core Sound Imaging’s Study Cast Cloud to be read online by 61 ASE physician members with Level II or more training. Remote physician readers participated from countries all over the world, including Bulgaria, Columbia, Egypt, Georgia, Greece, and Italy, as well as North America. After completing their reviews, our physician volunteers then rerouted this information back to India for use by onsite physicians; this information was used to inform follow-up care decisions.

Among the 1,096 patients that were scanned, serious abnormalities were detected in 60-70 of them. Among the echocardiograms that I reviewed from my office at Mayo Clinic were cases of rheumatic mitral stenosis, severe left ventricular dysfunction, hypertensive heart disease, and moderate aortic regurgitation. Thus, the imaging performed by the 17 physician trainees helped to identify conditions for which the adrenaline and phenylephrine drops used in cataract surgery are contraindicated. Patients in whom abnormalities were detected were then advised to seek follow up care at the local hospital under monitored settings.

This two-part project was truly innovative in a number of key ways. Not only did it provide local physicians in rural settings the opportunity to acquire new, potentially life-saving skills to improve patient outcomes, but it also gave ASE and its corporate partners the chance to test the viability of tele-medicine and tele-education in a fast-paced, clinical atmosphere. In the estimation of Dr. Manish Bansal, senior cardiology consultant at Medanta, the mission’s use of remote echo training constituted a watershed event in the history of healthcare delivery in India, which has the potential to change the way that medicine is practiced. The success of this real-time case study evidences echocardiography’s capacity to impact lives all around the world in substantive but cost-effective ways. Specific characteristics of this modality, including its portability and noninvasiveness, make it uniquely suited to improving global health outcomes, and we look forward to identifying new applications where it can make a difference.

There is tremendous interest in ASE mission work, not only by ASE’s many members who are eager to share their time and talents, but by colleagues in other sister societies internationally, who would like to collaborate with ASE or learn from our experience to conduct similar ventures. Several of our member physicians would like us to come to their home countries; indeed, efforts are underway to initiate mission work in Vietnam, Africa, and Cuba. Additionally, there is interest in providing services at free medical clinics that exist in inner city areas of the U.S. Drawing on the talents and expertise of ASE members with a passion for education, our new International Sonographer Training Task Force is developing curricula for promoting education in countries where the sonographer profession does not currently exist.

Presently, the greatest barrier to expanding our efforts is financial. Even though volunteers have covered their own travel expenses and we have benefitted from the generous support of industry partners, such as GE Healthcare, who gave substantially to the last two India missions, there are many expenses associated with each trip, and ASE staff members must devote their time to these endeavors. As you plan your contributions to various worthwhile causes, please consider making a tax-deductible donation to the ASE Foundation. This will enable us to provide more time and funds to support these missions. In addition to mission trips, our Foundation provides support for education (scholarships for several sonographer students and abstract presenters to attend our Scientific Sessions, and dissemination of our guidelines) and research (ASE’s several research grants provided annually). Your contribution helps to ensure a bright future for our profession!