Ultrasound experts – Ask a radiologist: Interview with Dr. Berndt Schmit

In our series of interviews with experts to understand the Covid-19 crisis and the context of ultrasound imaging and healthcare better, we start by speaking with medical expert, Dr. Berndt Schmit, Section Chief of Emergency Radiology and President of Humanitarian Radiology Development Corps. In this interview, Dr. Schmit gives his perspective about radiology’s role in addressing the Covid-19 crisis, how low resource settings are particularly affected, and what we each can do to help.

Dr. Schmit and his 501c3 focus on providing education, training and capacity development with radiology programs in limited resource locations including Nicaragua, Bolivia, Haiti, and Ghana. Humanitarian Radiology Development Corps donate ultrasound equipment and provide training on how to install and use the it. Our team sat down with him for an interview to ask him, as a health expert, what he wants the public to know about the Covid-19 crisis from a radiology perspective.

CW: Thanks you so much for joining me today. I’m really looking forward to hearing your perspective about what is going on with this global pandemic.

Dr. S: Hi Courtney. Glad to be with you on this beautiful morning. It’s hard to tell there’s actually a crisis going on.

CW: For folks, can you give us a brief snapshot of your background and the different areas in which you’ve worked?

Dr. S: My name is Berndt Schmit. I’m a board-certified radiologist and a full-time faculty at University of Arizona. I’m trained in Musculoskeletal radiology but now work full time as an emergency radiologist and actually started our program there last year.

CW: I’m also really interested in hearing more about your work with Humanitarian Radiology Development Corps, so if you could give a bit of background about that as well, that would be great.

Dr. S: I started working in third world countries four or five years ago and rapidly got experience with it. If you’re doing radiology work, it’s very equipment intensive and infrastructure intensive. I migrated from going to these countries to do work or educate people there, to realizing we had to help build their capacity to do radiology work. People essentially didn’t have fishing poles so we had to transition into the idea of we have to help them build fishing poles, maintain their fishing poles, so to speak.  So we started Humanitarian Radiology Development Corps about two years ago and we work now mostly in Haiti but we also have completed projects in Bolivia.  We are ramping up projects in Nicaragua and Ghana now.

We have a pretty large focus on donating ultrasound equipment and then doing the associated training to help the client become functional with ultrasound service.  We’re tip-toeing into much bigger projects.  One sound bite is we’re basically building imaging centers and radiology departments in the developing world.  Very challenging work.  Very fulfilling work.  What we’re trying to do is grow a Rolodex of contacts for people who can donate their time and for institutions who can donate equipment so we can do this heavy scale work that we’re doing.  

CW:  Thank you thank you so much for the background and the work you’re doing.  We really identify with it and think it’s really important.

Dr. S: There is a lot of debate in the field of radiology about what the radiologist’s role is as imaging specialists. Some organizations and people maintain that there is nothing particularly specific about Covid-19 that appears on chest films or CT scans, even ultrasound, so the role of a radiologist should be somewhat limited. Then, there is a lot of information from places that are doing a lot of work with Covid, such as Italians, Spaniards, Chinese, who are using a lot of CT imaging and bedside ultrasound.

There is some confusion or clarity that can still be developed around the concepts of triage – the idea is that you may not have a diagnostic imaging modality, yet you can use the imaging tool for management purposes or true triage. The concept of triage is a sort of grim concept, but triage really becomes relevant when you don’t have enough resources. Essentially, then physicians in charge have to make really difficult choices about who gets resources or not, which is a really uncomfortable way of saying some may have to die.

So, a lot of our country fortunately is not at that level, but I think we’re starting to see that in New York, and I’m pretty sure other countries have seen that when their system gets overwhelmed. I think that’s where putting the radiology hat back on, if you have a CT scan, it may not be specific, with Covid, if you have a tremendous amount of disease, that’s probably a sicker patient. It’s reasonable to make the assumption that that person has a poorer prognosis.

If you’re faced with two 30-year-olds who have disease and one looks really bad and you only have one ventilator left, this may help inform how you direct resources.  You may decide to use the resources for the sicker patient or you can imagine it’s if it’s bad enough maybe that’s a reason not to give that person that resource. I think imaging is such a powerful set of tools to get information and it doesn’t always have to be diagnostic, it may just be added information about severity or whether there are complications. 

When the dust settles in say in 6 months from now, we as radiologists will say, wow, imaging plays this huge role.  Maybe it’s not diagnostic, but boy can it be helpful in who gets admitted, who goes to an ICU, who gets a ventilator, what do we tell family members until lab tests come back. 

A problem we’ve had in the United States is that our lab testing takes so long. It’s slowly getting better it seems, but the market seems to be different in their experience.  If you’re facing five days of waiting for a lab test and a CT scan might be able to tell you that this looks pretty classic for Covid, it’s not specific, but you can go back home and if you have grandparents or family member with a renal transplant, they’d be very high risk for a fatal outcome.  

So again, imaging is such a set of powerful tools and we’re going to learn better how to manage it from a triage concept and from a management concept.

CW:  Just wondering, with all the different imaging modalities you have available, if you had just one at your disposal, which would you pick to combat the Covid fight, and why? 

Dr. S: Well, I’m talking to one of the best ultrasound entrepreneurs in the world, probably, so I should say ultrasound –

CW: Haha, no, you shouldn’t!

Dr. S: As radiologists, oddly, we don’t use much ultrasound for lung and pleura imaging but as I am working more and more with emergency doctors, they do. So getting on a learning curve about that. It sounds like ultrasound has been very helpful at the bedside for the actual ICU physicians in Italy. Being able to do a quick imaging test to tell are things better or worse without having to bring in a machine, expose the CT technologist to that patient… you have someone already in a sealed suit in the room pull out a handheld ultrasound device and just answer the question “Is there more or less lung disease?” It gives a clinical picture and helps them make decisions.

I think in the context of “Are you in an ICU, do you have a really sick patient?” ultrasound may actually be a really helpful tool. It’s so portable now the logistics around it are much simpler. That said, CT probably gives the most information. We can see the lung really well, we can see the pleura really well. It’s still not specific, as we discussed, but boy, your ability to see things. In the early phase of the Covid infection is when you might see characteristic features that might be Covid-suggestive, shall we say. Later on the lung just gets so horrible we talk about end stage lung, or ARDS appearance and that’s not specific really at all.

CW: Got it. And I’m curious, with all your international experience and the global mindset that you bring to your practice, what are you hearing about the places you work with for example in Nicaragua and Haiti? How are they handling the crisis. We hear a lot about Italy, we hear a lot about Europe, maybe a little about Asia as well. But we haven’t heard as much about the emerging economies of the world that are having to tackle this challenge as well.

Dr. S: Great question! I wish I could travel cause I’d love to go see firsthand but I read a newspaper article about Nicaragua, and it just sounds like they are promoting social activities in a denial phase of things. That’s really scary because that’s not a good approach to a respiratory infectious agent. I have a couple contacts in Haiti I’ve talked to and it sounds like they are just starting to see the disease there. I don’t know what their testing capability is. I don’t know if they’re sending lab tests out to say to the United
States somehow. Or if they’re doing local tests. But it sounds like they have proven Covid cases.

The problem in a resource poor environment is that there aren’t enough ventilators, there are not a lot of physicians who are good at handling severe ICU cases. The terrifying part is that the population density in slums is so high the idea of social distancing is somewhat fantastical.

I have been listening to some news reporters from India and other places and the idea of being able to wash your hands multiple times a day is a real luxury. You have to have clean water, you have to have soap. For the poorest of the world, that is fantastical. They won’t be able to do that.

I think the terrifying part for a country like Haiti is that once Covid gets going, it could be a massive, overwhelming pandemic. There are no places for these patients to go. They can’t spread out, there’s no high quality healthcare facilities. These are places that were overwhelmed before health crises like Covid. I think about the poorest parts of the world and I think Covid could just be an incredible horror show.

CW: This is devastating to hear. In closing, what do you recommend? As a lay person what can I do, both here in my home country and what can I do for those abroad?

Dr. S: Wow, so what I think we’re doing right now with social distancing seems to be working, and working well. So, in a wealthy country where we live in individual homes and we can move around in cars that are kind of hermetically sealed, we have some fantastic options. If we were just disciplined as a society, we may flatten the curve, to the point that only a modest number of people have the disease at any point and our healthcare system should be able to handle that fairly well. It’s going to be expensive, it is going to be disruptive. But we have options. If we’re careful about what we do, if we don’t just ramp up the economy quickly and tidal wave back into crowded environments like restaurants or stores, I could see the United States doing ok.

I think six or 12 months from now when we look back, we’ll say well New York is a really unique environment. The subways – I’ve been to New York a bunch of times – the restaurants there, the stores there, everything is so much more crowded. When you’re talking about a respiratory droplet spread infectious agent, that the kind of way you can spread it effectively. A slum environment, high density environment, a mass transit environment, it is going to be a good mechanism for spread.

If the rest of the country can somehow make do with current social distancing, maybe we’ll have to explore with how you have limited return to work and limited return to school, we may do okay. I think that’s the personal, what we as individuals can do. What we’re doing now seems to be helping, helping a lot maybe.

On a bigger picture, we’ll look back and wonder why did the richest country, most technology-advanced, highly informed society not prepare well? A lot of people will do the political spin, maybe we did or didn’t, but frankly no. We didn’t prepare well and there should be some lessons learned. Hopefully we don’t spend too much time pointing fingers, but rather we have to think about how we can organize our actual healthcare system into something that is integrated and can respond as a whole.

It’s an interesting thing to think about. If we have a million ventilators in the country we don’t need a lot of them in Kansas right now, but we sure need a lot of them in New York. If we were an integrated healthcare system with say a Ministry of Health that could be done. We could move all the ventilators to New York, and as they finished their curve, we could move them to Kansas or LA or wherever the next surge of disease is.

But we’re not an integrated system, we don’t have leadership, and into that vacuum has stepped a very politicized government and we have a mess of slow response and it’s unfortunate. Hopefully on the other side of this, we’ll as a nation we’ll think about can we better leave healthcare, and provide physicians and experts with clinical knowledge.

CW: I for one think Dr. Schmit for the first Minister of Health in the US would be awesome. Truly, thank you so much for sharing your expertise with me and helping us understand the context of the crisis not just here but globally. It’s really important. Thanks for letting us for rely on your expertise. We’re grateful for the expertise you bring to us and the rest of the world, so thank you.

If you’re interested in learning more about Humanitarian Radiology Development Corps and how you can help with education and capacity building in their projects in Haiti, Nicaragua, Ghana, and Bolivia, contact bpschmit12@gmail.com or visit: hrdcorps.org.