The need to provide medical evaluation and care for displaced peoples is evergreen. Recent instances include the acute need for medical aid of victims of the Israel-Hamas war and the Russia-Ukraine war. Lessons from previous emergency triage incidents, such as the mass evacuation of allies from Afghanistan in 2021, offer valuable insight into how point-of-care ultrasound (POCUS) can aid in the medical triage process.
In April 2021, the U.S. announced the intention to remove all troops from Afghanistan by September 2021. The drawdown of U.S. forces in Afghanistan through the 2021 summer was met with the collapse of the Afghan government as the Taliban took control. This led to the largest non-combatant airlift in U.S. history. The Philadelphia International Airport (PHL) was one of two designated receiving ports in the U.S., and ultimately became the sole designated receiving location for Afghan evacuees. PHL received over 25,000 evacuees from August through October 2021. A medical response team, with leadership by emergency medicine physicians, formed in partnership with local and federal agencies and the Philadelphia receiving hospitals.
Medical screening and support at the airport was an emergent call. The ultimate goal: to determine who needed immediate advanced medical care in an emergency department or hospital setting, and who could receive basic urgent care at PHL and be referred for ongoing evaluation at subsequent U.S. military base destinations. During this time, POCUS became an essential diagnostic tool in the medical triage process. But even prior to this incident, POCUS had been known to be a valuable tool, particularly in limited-resource field care settings. For example, one study from France showed that 302 prehospital ultrasounds performed by ultrasound-trained emergency physicians improved diagnostic accuracy in 67% of the cases.
Every evacuee arriving to PHL from Afghanistan received a medical screening examination if they reported symptoms of concern or a desire to see a medical professional. They walked along designated pathways marked with clear signage to a medical triage area, where a clinician (medical lead) performed a rapid assessment of the patient’s chief complaint and general appearance. Then the assigned onsite medical team conducted a history and physical examination. An in-person Dari, Pashto, or Farsi language translator assisted as needed. From there, the medical team determined if the patient needed point-of-care diagnostic testing (e.g., POCUS examination, urinalysis, pregnancy test, glucose test, or COVID test). If more advanced care was needed, on-site ambulances transported patients to the closest, most appropriate hospital after a verbal sign-out by PHL medical command.
Clinicians performed POCUS examinations using a Butterfly iQ or a Philips Lumify handheld ultrasound device. The most urgent diagnostic considerations for which emergency physicians used POCUS: pregnant women to confirm an intrauterine pregnancy and a fetal heart rate, estimating dating in advanced pregnancy, patients with leg symptoms to evaluate for a deep vein thrombosis, and patients with shortness of breath to evaluate for pulmonary edema or a lung consolidation to suggest pneumonia. For patients with skin and soft tissue infections, POCUS assisted in determining if the infection needed incision and drainage or simply antibiotics. Finally, patients with abdominal pain were evaluated by POCUS to look for gallstones. The POCUS confirmation of viable intrauterine pregnancy and dating can be a vital part of care in humanitarian crises and among displaced populations where pregnant women are more vulnerable. In this case, displaced mothers and clinicians could be reassured on safely continuing on the journey to permanent placement, or triaged to hospital level care.
To ensure POCUS examination quality, the patient’s name and birthdate were stored on the ultrasound device along with the POCUS images. If a diagnostically clinically relevant finding by POCUS was identified, this was recorded on the patient’s paper chart and via a hand-typed note on a blank screen of the device. POCUS trained physicians reviewed these images to ensure the accurate diagnoses and care were provided to the patient.
POCUS has a substantial impact in settings of limited resources. In 2021, this modality not only aided in the diagnosing of patients but also in directing the medical management of Afghan evacuees presenting to the Philadelphia International Airport. The use of POCUS can have widespread implications in care provided to populations displaced by humanitarian crises across the globe.
Kaylah Maloney, MD, is an assistant professor of emergency medicine at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. Arthur Au, MD, is a professor of emergency medicine at Thomas Jefferson University in Philadelphia, and fellowship director for the Point-of-Care Ultrasound Section. Patricia Henwood, MD, is the chief clinical officer at Jefferson Health in Philadelphia, and associate professor of emergency medicine and population health at Thomas Jefferson University. Jessica L. Patterson, MD, is an associate professor of emergency medicine and director for the AROW (Austere, Remote, Operational, Wilderness) Fellowship at Lewis Katz School of Medicine at Temple University in Philadelphia. Efrat Rosenzweig Kean, MD, is the director of clinical trials and clinical assistant professor of emergency medicine at Thomas Jefferson University. Resa E. Lewiss, MD, is a professor of emergency medicine at the University of Alabama at Birmingham, a consultant in telemedicine point-of-care ultrasound for Médecins Sans Frontières, a physician health designer at Perkins & Will, and host of The Visible Voices Podcast.
Disclosures
Henwood is the founder of Point-of-care Ultrasound in Resource-limited Environments (PURE) and previously received equipment support from Philips Healthcare and Butterfly Network. Lewiss serves on the medical advisory board for EchoNous, on the board of PURE, on the board of the Society for Clinical Ultrasound Fellowships, and previously received equipment support from Philips Healthcare and Butterfly Network.
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