 So, Adi. Good morning. Today we're going to talk about point-of-care ultrasound. Point-of-care ultrasound, okay, that's pretty good. Yes, or Pocus for short. But first I just want to describe a little bit of my disappointment that we did a proof-of-concept study in South Sudan with six clinical officers who are mid-level providers who are our main clinicians and one of them was actually supposed to come here and do the presentation. And his name? Justin. Big shout out to Justin. I don't know where you are but if you're watching the live stream we love you and we miss you. Yeah and sorry his visa got rejected so he wasn't be able to be here. So I'm going to describe a little bit about what is point-of-care ultrasound and what we're trying to do here. So Pocus or point-of-care ultrasound really is the ability to use very portable ultrasounds at the patient's bedside by non-radiologists. And so what they do is you use ultrasounds in a simple pattern recognition with a simple algorithm and you answer binary yes or no questions in order to aid your clinical decision making. Okay that's clear. And so there's about three innovations that have happened over the last 10 years that have made it really easy to use in our fields. One is the prices come down a lot. What used to be tens of thousands of euros has now made machines less than 20,000 euros and probably in the next couple years even less than 10,000 euros. The second is the size. So what used to be these large machines that you could imagine have turned into something that fits in a MSF standard issue logisticians cargo pants. In your back pocket type of thing. Look literally in your cargo pants. In my cargo pants is the ultrasound. This is it. It works with any tablet or basically there are about six different tablets that work and you have a probe and this probe right now is about $300 a month or about $8,000 to buy. You simply plug the probe into the tablet. It turns on by itself. Maddie do you want to come around and you can have a quick look what's going on here. You have an ultrasound and what we do is this is Eddie who's an excellent from Canada who's our demo. Let's pretend you're ill Eddie. We did this having a baby. We did this proof of concept with children less than five years old in South Sudan. We don't have a child here but you've chosen the biggest man in the building to demonstrate on and we'll show but basically what a clinical officer or any clinician can do in the field is just take this ultrasound at the bedside kind of wipe it in different patterns on the left side on the patient's right side on the patient's left side on the patient's side and then on the patient's back and with that when following a simple algorithm you can go ahead and sit back Eddie. You can almost tell whether the patient has fluid outside the lungs such as what's called chloral effusion which may be things like tuberculosis. You can think about pneumonias whether they have fluid inside the lung caused by sepsis or by heart failure and you can get a lot of information right at the bedside and the reason this works is because it's a simple pattern. You're looking for binary questions is the pattern vertical is the pattern horizontal and we're able to teach this to non radiologists and what that means is that not only can we teach multiple doctors but we can task shift this and allow a lot of our mid-level providers midwives our other national staff to be able to answer pretty impressive clinical questions. There are all for the next steps for MSF there are already a lot of algorithms that we should be implementing right now for trauma to be able to tell if somebody has excess blood in their abdomen or on their heart for obstetrics and pregnancy of course we need to be able to teach our staff but also there are new algorithms and protocols that we need to research for our patients. A lot of the algorithms have already been done in the developed world where there's lots of specializations and our fields we know that there's diseases like malaria and tuberculosis and HIV and malnutrition that are not at all the same and we need to come up with new protocols to be able to help these patients. Okay that's fantastic. So how far are you in the development of this? It's been field tested you say already and... Absolutely over the last year I've used it myself. I spent nine months in South Sudan and I use it almost every day and in fact we did a research study as a proof of concept. Can we teach clinical officers which are these mid-level providers? They each did 60 exams each and those 60 exams were sent to two expert reviewers. We finished in March and the expert reviewers are still finishing reading all all the exams. One of them has already finished and the concordance rate between him and the clinical officers is approaching 90 percent so they did great. Fantastic well that's really good news we've got time for one more question Dr Vargavi. Adi I have to say as a clinician I've always thought of ultrasound as a complete black art so this sounds incredible that if it's actually able to make it easy just for non-radiologists like myself but also nursing staff to use this. I don't know if you know but through the lab working group in MSF we're trying to recommend that we have ultrasound available at all primary care facilities ideally. But can you tell me like if you are using this with non-clinicians is it a kind of rule out or a rule in type of diagnostic tool? Yes so for all the non-radiologists it's a rule it's a rule in so this test is in epidemiological terms very specific and a little less sensitive so for example we can use this for appendicitis and if I do an ultrasound on Adi and I see an appendicitis absolutely this Adi has appendicitis sorry Adi and he needs he needs to get seen by a surgeon immediately but if I don't see it it doesn't mean that he doesn't have it and I still need to incorporate this into my clinical decision-making does he have fever does he have abdominal pain is he vomiting has he had any other surgeries and this is one of the things that we it why we call a point of care ultrasound is it's integrated into the clinical decision-making by all the clinicians. Okay great thanks very much bravo and good luck Adi getting better