 Thank you. It's an honor to make this presentation for two reasons. The first is to present the work of our South Sudanese staff, but also because ultrasound is awesome, and it's something that as a clinician it really is it's changed the satisfaction that I and our colleagues who do ultrasound have in the field and it's made a market improvement in the care we can and do provide. So this is the feasibility of training MSF clinical officers in point-of-care ultrasound or Pocas, not Pocas, but Pocas, for pediatric respiratory diseases in Awil, South Sudan. So first is to give a background on what is Pocas. The Pocas is not becoming a radiologist. It's not high-level specialization. It is the use of portable ultrasounds by non-expert clinicians using simple pattern recognition to answer clinical questions at the patient's bedside and to make a decision in real time. There's a lot of information in that sentence, but we can really see the example. This is Jonas who is doing an ultrasound. He has a small portable ultrasound machine at the patient's bedside. He's been trained on how to use simple algorithms or simplify complex ultrasounds and at the patient's bedside, he acquires the images and makes a decision in real time. There are many different types of Pocas applications. The original classic one is called eFAST or Extended Focus Assessment of Sonography in Trauma. And what this is, is for patients who are suffering from trauma, you do a quick ultrasound around the abdomen and thorax to see if there's any excess fluid which could represent blood. And then you determine if there is. In that context, maybe you have to find a surgeon or refer the patient to surgical services. It's been widely used in emergency medicine and it's validated quite well. But past that, over the last 20 years, people have simplified other ultrasound uses also. So now we have basic cardiac, which instead of a large echocardiogram study, you really are just trying to find what is the left ventricular function. Is there fluid around the heart? And is there any right ventricular strain? Long ultrasound is big and popular and we'll talk about that in a couple of minutes. You can also do ultrasounds to screen for any pregnancy emergencies, either in the early pregnancy or late pregnancy state. You can use it for procedural guidance, which makes a procedure much safer, whether it's doing a thoracentesis or paracentesis, which is to remove excess fluid from the thorax or from the abdomen, respectively. You can use it for soft tissue to find abscesses and you can even use it to diagnose fractures in places where there are no x-rays. The objective of our project was to evaluate a training exercise. Can clinical officers efficiently learn a long ultrasound algorithm to diagnose respiratory pathologies? We were already doing ultrasound in our project and we wanted to test lung ultrasound specifically for two reasons. One, as you know, lower respiratory infections are a leading cause of mortality in children under five worldwide, including in our wheel. Second, lung ultrasound is moderately complex and so if clinical officers can learn this at a high enough level, we can infer they can probably also learn other ultrasound usages in addition. So a little bit technical slide and we'll try and simplify this and not get too bogged down in the details. But what you'll realize about POCUS or this simplified ultrasound is it's really pattern recognition. So we'll go one at a time here. If you look in the top left slide, what you see is you see the brightest white lines closest to the top of the screen. That's the pleura or the outside of the lung. If you look below that and you see horizontal lines, those are called A lines. And for the context of this presentation, to put it very simply, you can consider that to be air inside the lung. On the top right, you have again the brightest white lines towards the top of the screen. That's the pleura line. But here instead of the horizontal lines, you see these vertical lines. For our discussion, we can say that's fluid inside the lung. In the bottom left, you see again the pleura, the brightest white line. And below it, there's something that looks more solid. That's consolidation or potentially pneumonia. And then finally, you see on the bottom right square, you see the bright line. That's the pleura here in the middle of the screen. And above it, you see black, which is liquid. And that's a pleural effusion. You can take these four ingredients of lung ultrasound, plus a couple of others. And then you can kind of do an ultrasound around, especially children who do it all around their lungs and make an ultrasound diagnosis. This is a little bit too technical for us, so I'm going to skip past this right part of the screen. So what we did was we recruited six clinical officers. And you can see them early morning taking the written part of the examination for the application. And they each underwent 12 hours of field-based training. Subsequently, each of them performed 60 lung ultrasounds. They submitted both the images of the lung ultrasounds, but also what was their interpretation of the ultrasound. We had two expert graders review and grade all the ultrasound images with a tiebreaker for any discordant results. The experts reviewed them under two areas, or they used two different methods. First was a very simple binary score. Are the images provided by the clinical officers appropriate? And is their analysis of the diagnosis acceptable? So that was one system. The second system was a five-point-lickered scale, one being very bad and five being excellent. Our hope was that they would get at least four. Four being that their ultrasound met the minimal criteria for diagnosis. All the structures were imaged well, and the diagnosis was easily supported. Five being that it met the minimal criteria, the images were excellent, and the diagnosis completely supported. Because this was a training exercise, there were no clinical decisions changed because of the clinical officer's ultrasound. All the caretakers gave consent, and this was approved by the Ethics Board of the Ministry of Health of South Sudan. When we get to the results, when we look at the binary yes-no questions, the expert reviewers found that 99% of the clinical officers' ultrasounds were acceptable. There were good images that can be graded. They found 86% of the clinical officers' diagnosis was accurate. On the littered scale, they graded an aggregate 4.11 for all 355 of the exams. We looked a little bit at the inter-rater agreement, the Kappa between the clinical officers and the experts in aggregate. And for consolidation and bronchiolitis, they were substantial agreement. For interstitial syndrome or this bunch of pulmonary edema, it was only moderate. And finally, it took about, on average, 15 minutes for each of the clinical officers to do one ultrasound. The limitations of this study are one that mainly this was an evaluation of the training itself, not of the diseases of the lung. Second, we didn't have a comparison to chest x-ray, mainly because there was not a chest x-ray on site in a wheel. It's about a 15-minute drive away. Also, there's a lot of recent literature that shows that lung ultrasound is at least as equal to chest x-ray, especially in pediatrics. There was a 24% discordance rate between expert 1 and 2, which the tiebreaker expert graded. And the average time of the lung ultrasound was 15 minutes. So our conclusions are that clinical officers in South Sudan can effectively learn a lung ultrasound algorithm to diagnose respiratory pathologies. However, additional work needs to be done to standardize the definition and decrease the time per exam. I wanted to take a couple of slides in a couple of minutes to talk about some of the next steps that we've been doing since this. So we've been working in collaboration with the Diagnostic Imaging Working Group in MSF. We also received an incubator transformational investment capacity grant hosted at MSF USA. And the goal is to pilot field-level focus implementation and find a model for Scala. Currently, we've started implementation of comprehensive focus package in South Sudan. So in January, we were in Awil, in February, Agak, and in March in Malacal. In total, we have 29 South Sudanese staff trained. This includes clinical officers, doctors, and midwives. We've been working on creating and adapting proper training modules, but also making sure that the ultrasound, the focus is integrated into hospital flow. And this is quite an important step because the way we say it is, you have to know when to use an ultrasound, but you also have to know when not to use an ultrasound. This is because it does take time to do an ultrasound. Not all ultrasounds take 15 minutes, but it does take less time. And ultrasound has to be absolutely integrated into your clinical care. It matters that you do a proper history, a proper physical exam. You use your other rapid diagnostic tests. And as much as I do love ultrasound, I will readily concede that bedside hemoglobins, bedside rapid diagnostic tests from malaria and other diseases, bedside capillary glucose probably save more lives. And those are the things that are most important. And we have to make sure that as we implement ultrasound, that we are ensuring that the clinicians continue to use all these other tools at their bedside for the patients. We're working on seeing which of the different ultrasound machines are most adapted to our fields. We're still trying to work on a longitudinal learner tracking within MSF, especially for these students. This is a little bit harder and it's going to still take some time to start implementing. And then another thing that is quite important is that there has to be a link with the MSF telemedicine. Outside of ultrasound, one of the most amazing things that I've seen in MSF is the use of telemedicine. The reason it's absolutely important for ultrasound is because as we are teaching non-experts and simplifying ultrasound, what they're going to find very quickly are things beyond their training. So they may find something on the liver that they were not trained for. They might find something in the heart such as a contral heart disease or advanced rheumatic heart disease that they don't understand. If we were working in a hospital in a developed setting, what you would do is you would order a CAT scan. You would get a consultation of an expert. But we don't have those in our fields. What we do have though is this amazing system of telemedicine where you can be linked from the field to experts around the world, including at headquarters. And so this is a crucial integration with POCIS. What we need to do to further this is we need to optimize the highest utility applications. We also need to understand the budgetary implications. This is not a trivial cost in MSF. The ultrasound machines over time will get less expensive, but there is a cost to implementing ultrasound and doing the training. And it's absolutely important that we have to integrate the medical departments and the operational cells who need to take ownership of these. These are ultrasounds that are being used in medical activities with our staff. And if we can do this, then we can systematically scale up POCIS through training, workflow, and monitoring. In addition, a lot of the POCIS world, these ultrasounds, have been developed in high resource settings. But we clearly know that these high resource settings are not the same. They don't have as much malaria, tuberculosis, or HIV, malnutrition that we do in some of our fields that our patients suffer from. And so we have to consider a research agenda to adapt POCIS to the needs of our patients. And this includes adapting cardiopulmonary to patients in areas where there's a high amount of malaria, rheumatic heart disease, HIV. Thinking about using POCIS to diagnose extra pulmonary tuberculosis, screening for rheumatic heart diseases, potentially using volume status in children with malnutrition, and even to advance the care of diagnosing fractures in areas where there are not any x-rays. And with that, I'd like to first thank the six clinical officers who participated. They are amazing people, and I hope we found a way to get them to watch this live. Otherwise, I will get them a video of this. But Justin, Steven, John, Santino, Moses, and Mazureka, they put in so much time in order to do this. But also the reviewers, Norton and Claire as the medical directors, the medical coordinators and the deputy medical coordinators in South Sudan, and of course, Kerry Teicher, who has been my partner through this whole ultrasound experience. So with that, I'm finished.