In the United States, ER patients with suspected pleural effusions or intra-abdominal bleeding are routinely sent to radiology for chest X-rays or CT scans as part of diagnostic protocol. In much of Ghana, however, that same imaging is delayed until the patient can pay for it upfront. What should be a clinical decision becomes a financial one.
For EM clinicians working in resource-limited settings, these financial limitations impact how fast they can diagnose and treat patients. To help close the gap, in April of this year, Brent Heimlich, PA-C, and three ultrasound fellowship-trained EM physicians from Massachusetts General Hospital’s Center for Ultrasound Research and Education (CURE) traveled to Ghana’s second-largest hospital, Komfo Anokye Teaching Hospital (KATH) in Kumasi, to teach local EM clinicians how to use cost-effective ultrasound tools. Below is a look into the financial barriers facing Ghanaian EM, and a discussion on how PA Heimlich’s trip made a lasting impact on all involved.
When the Price of a Scan Delays Care
In Ghana, cost-effective services are a necessity: Although the country has had a National Health Insurance Scheme (NHIS) in place since 2003, out-of-pocket (OOP) healthcare expenditures remain a major hurdle. Research indicates that OOP payments account for roughly 26% of the country’s total health expenditures, which far exceed the WHO’s recommended threshold of 15% to 20%.
For patients requiring emergency care, advanced diagnostic imaging presents a particular financial burden, as it’s rarely covered by NHIS. A study evaluating trauma care at KATH, a 1,200-bed tertiary referral center that sees tens of thousands of emergency visits annually, found that 60% of uninsured patients and 33% of insured patients incurred catastrophic health costs. The requirement to pay upfront for X-rays and CT scans acts as a literal barrier to lifesaving care.
Empowering Clinicians at the Bedside
And yet, X-rays and CT scans are not the only diagnostic options available for EM patients. One key alternative is point-of-care ultrasound (POCUS), a handheld probe clinicians can provide to patients for free at the bedside. POCUS has made significant changes to EM practice in similar settings to Ghana, and has been credited with catching high-risk pregnancies earlier, reducing unnecessary referrals, and lowering maternal and neonatal mortality. The probe identifies concerns like effusion or signs of internal bleeding in real time, without a trip to radiology or a prohibitive bill.
While the clinical utility of POCUS is well-documented, knowledge about the tool is still not as widespread as it should be. KATH, despite hosting a robust EM residency, lacked EM physicians with fellowship training in emergency ultrasound.
This combination of proven track record and underutilization was precisely what motivated the CURE team to travel to Kumasi to lead a comprehensive POCUS course. “POCUS is a safe, efficient, and cost-effective tool, especially in resource-limited settings. For example, it is highly effective in the management of emergent conditions, such as expediting the diagnosis of ectopic pregnancy, detecting intra-abdominal bleeding in trauma, or diagnosing pericardial tamponade, life-threatening conditions that are easily missed without ultrasound,” PA Heimlich shared in a report on his experience.
Rather than a standard “drop-in” global health trip, the CURE team’s initiative was part of a longitudinal partnership with KATH established in 2019. The team designed a targeted three-day POCUS course specifically for KATH’s EM residents and attendings, with “didactic lectures on topics ranging from cardiac echo and DVT to hepatobiliary and even ultrasound-guided procedures including LPs and an array of upper and lower extremity nerve blocks,” according to PA Heimlich.
The true test of the CURE curriculum occurred on the third day, when training moved from the lecture halls directly into KATH’s Accident and Emergency ward. The CURE team and the newly trained KATH clinicians were assigned to the “red zone," i.e., the department’s highest acuity area. The transition from theory to real-world application was immediate. During one clinical encounter, PA Heimlich said, “We found a large pleural effusion on ultrasound which the team [was] able to rapidly drain with a thoracentesis to improve the patient’s breathing.”
Global Health Impact
In resource-limited settings, POCUS serves as both a clinical tool and a financial equalizer. By bringing handheld ultrasound directly to the bedside, clinicians bypass the hospital billing constraints that historically delay imaging.
Global health initiatives in EM often struggle with sustainability, but the CURE team’s approach offers a replicable model. By focusing on hands-on application in the wards, the course was designed to foster clinical autonomy. As KATH clinicians strengthen their own ultrasound skills, they can go on to train their junior colleagues. This creates a self-sustaining loop of education that outlasts a single visit.
The relationship also extends beyond the physical trip. The CURE team plans to implement real-time tele-ultrasound guidance, which allows remote clinicians to help acquire and interpret images over live audio and video to support KATH clinicians whenever the need arises. It is an ongoing partnership rooted in mutual respect. “I feel incredibly fortunate to have had this opportunity to not only teach emergency ultrasound but to learn about a culture and health system I previously knew little about,” said PA Heimlich.
A travel grant from the Doximity Foundation covered airfare for PA Heimlich's work. The Foundation offers travel grants to physicians and APPs who are making a global health impact.
