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Changing Your Frame of Reference

Changing Your Frame of Reference. Standards of Care in HA Operations. “Two Standards of Care”. Understand “Two Standards of Care” Empiricism - relying on hunches more than hard data Medical Supplies WHO Emergency Health Kit. The Non-U.S. Standard of Care.

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Changing Your Frame of Reference

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  1. Changing Your Frame of Reference Standards of Care in HA Operations

  2. “Two Standards of Care” • Understand “Two Standards of Care” • Empiricism - relying on hunches more than hard data • Medical Supplies • WHO Emergency Health Kit

  3. The Non-U.S. Standard of Care • Other people have the same values, morals, ethics • They lack the same resources • $8 per person per year

  4. Who Provides Health Care? • Nurses and community health workers • Little to no supervision by a physician • In an HA op, there will not be the HM/MO to patient ratio we are used to: • train refugees/IDPs as community health workers • train Marines, soldiers

  5. The Best Thing for Medical • Training Others to perform medical tasks is the most valuable use of our time • Oral rehydration • Health education • Disease surveillance

  6. Who is Treated? • No extraordinary measures • Don’t do something if it cannot be sustained • why resuscitate a heart attack victim if there’s no ICU for the patient to recuperate? • Why resuscitate a premature infant if you cannot support him afterwards?

  7. How do you treat? • IV therapy is extraordinary treatment • expensive (man-hours, sterile supplies) • Greater reliance on oral and intramuscular medications • Convenience and ease of administration are forsaken for cost and durability of medicines • No lab or X-ray; no time for in-depth diagnosis (up to 60-100 patients per day per doc)

  8. What is Used to Treat? • No comfort meds (cold and cough remedies) • Low cost, low glamor antibiotics

  9. Strive Hard to Maintain the Two Standards of Care • Do not stir up ethnic strife by inadvertant favoritism • Do not make the refugees more unwelcome than they already are by exceeding the standard of care of the host country • Don’t set a standard you can’t sustain • Set a policy for civilians/refugees injured by USMC activities

  10. The WHO Emergency Health Kit • Developed by UNHCR, London School of Tropical Medicine, UNICEF, Doctors without Borders, International Red Cross) • Driven by prior failures • Reliable, standardized, proven, durable, inexpensive, appropriate • Packaged for durability (can be air-dropped) • Inventory used as model for whole nations’ drug supplies

  11. WHO Kit Set-up • Designed to support 10,000 patients for 3 months • 10 Basic Units: oral and topical medicines • 1 Supplementary Unit: injectables 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 10,000

  12. Specialized Kits • Measles Vaccination Cold-Chain Kit • 5000 immunizations

  13. Supplies in the WHO Kit(selected list) • Antibiotics (very basic) • Oral Rehydration Salts • Pressure Sterilizer • Kerosene Stove • Weight / Height Charts • Clinical Guidelines

  14. The Antibiotics • Penicillin V • Penicillin G IM • Penicillin G IV • Ampicillin • Septra • Chloramphenicol • Tetracycline

  15. Penicillin V • 250 mg tabs (4000) • child 25 - 50 mg / kg / d divided q 6-8 h • adult: 1 tab po qid • Indications • Minor respiratory • head and neck infecitons • oral anaerobes, group A strep

  16. Penicillin G and Bicillin IM • Procaine IM only (1000 doses) • child: 25-50 k units / kg / d divided q 12 h • adult: 300 - 600 k units q 12 h • Bicillin (50 doses) • depot shot q 15-30 days • Indications • Mild-moderate versions of: • respiratory infections • head & neck infections • oral anaerobes, strep

  17. Ampicillin PO / IM / IV • Ampicillin PO (2000 tabs) • child: 50 - 100 mg / kg / d divided q6h • adult: 2 - 4 g / d divided q6h • Ampicllin IM / IV (200 doses) • child: 100 - 400 mg / kg / d divided q4-6h • adult: 6 - 12 g / d divided q4-6h • Indications • moderate-severe respiratory infections • neonatal sepsis / meningitis • better gram-negative coverage than PCN

  18. Septa • 80 TMP / 400 SMX tabs ORAL (20,000 doses) • child: 8 - 12 mg TMP /kg/d divided BID • adult: 1 - 2 tabs PO bid • Indications: • mild-moderate respiratory conditions • skin infections • UTI • cholera and dysentery • Watch out for sulfa allergy and bone marrow suppression

  19. Chloramphenicol • Oral: 250 mg tabs (2000 doses) • IM / IV 1 g injections (500 doses) • Doses: • < 1 wk: 25 mg/kg/day • > 1 wk: 50 mg/kg/day div q12h • > 4 wk: 50 mg/kg/day div q6h • child/adult: 100 mg/kg/day divided q6h

  20. Chloramphenicol continued • Indications • Excellent penetration of all body fluids • Use for all serious infections • sepsis • meningitis • respiratory infections • bone / joint infections • typhoid, cholera, dysentery

  21. Excellent Bioavailability of Chloramphenicol

  22. Toxicity of Chloramphenicol • Reversible dose-dependent bone marrow suppression • Aplastic anemia (1:40,000 recipients) • occurs weeks to months later • not dose related • Gray Baby Syndrome • overdosing in infants --> flaccidity, cyanosis • Hemolytic anemia in G6PD deficiency

  23. Tetracyline • PO: 250 mg (2000 doses) • child: 25 - 50 mg/kg/day div q6h • adult: 250-500 mg q6h • Indications: • mild-moderate respiratory infections • cholera, dysentery, malaria • Toxicity • stains young teeth: don’t give to pregnants or kids < 8 yrs/ old

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