Common Problems

1. Common Problems Eloise Harman Based on 16 years with PH

3. Project Haiti • Started by Serge Geffrard, then a second year medical student in 1996-in Serge’s words “Having grown up in Haiti, I have always had a passionate desire to be part of a medical trip to my native country” • Without Serge’s passion and ingenuity, there would not be a “Project Haiti”

4. PH History • In Fall 1995, Serge, recruited several other students and a physician in private practice to go to Haiti during Spring break 1996 • They stayed at an orphanage • The physician couldn’t tolerate the conditions (and the gastroenteritis) and left after 3 days • Serge persisted and with the help of Dr Parker Small, went back with a better organized group and 2 faculty in 1997. Serge also asked Dr Art Fournier of Project Medishare (U Miami) to accompany the group

5. Project Haiti was the pioneer for international service projects at UF

6. Common Problems • Organizational • Medical • Behavioral

8. Crowds and Organization • Develop organizational plan including triage and crowd control • Use the help of local people to maintain the organization • In advance, pack and label commonly used drugs like NSAIDs, Acetaminophen, vitamins • Limit the number of medicines that you give to an individual • Develop a system to mark people (eg children already given worming medicine)already seen to avoid repeaters

9. At each location take a few minutes to scout out the available sites for exams and figure out where the people will wait and the location of the pharmacy • One entrance and one exit • Triage • Obtaining a detailed history of a complaint may be difficult. Try to think of key questions. • Use observation, vital signs, common sense to determine who is really sick

10. Medications • Use caution and avoid giving multiple medications • Ask if they are already taking medication • Childproof containers may be desirable but teaching how to open them may be problematic • Ask women if they are pregnant or nursing • Label every drug clearly with name and strength and write directions in the local language or with pictorial labels

11. Medication Label for Non-Readers Werner, Where There is No Doctor, 1992

12. Common Complaints • Fever • Itching/rash • Cough/wheeze • Malaise • Joint pain • Epigastric pain • Headache • Dysuria/discharge

13. Who’s Really Sick? • Change in level of consciousness • Unable to walk unassisted • Breathing fast/using accessory muscles • High fever • Bleeding/injury

14. Common Conditions • Skin rashes • Asthma/bronchitis/URIs • UTI/Vaginitis/STDs • PUD/parasites/H. Pylori • DJD/muscle strain • Pregnancy • Hypertension • CHF • Malnutrition

15. Skin Conditions • Cutaneous fungal infections • Impetigo • Scabies • Atopic dermatitis

16. Impetigo • A bacterial skin infection (staph aureus, strep pyogenes or combination • A red macule or papule progresses to a vesicle which ruptures easily to form an erosion, with characteristic honey-colored crusts that may be pruritic . • Often is spread to surrounding areas by autoinoculation. This infection tends to affect areas subject to environmental trauma, such as the extremities or the face. • Spontaneous resolution without scarring typically occurs in several weeks if the infection is left untreated

18. Impetigo treatment • Treatment is usually topical (mupirocin-Bactroban) • Oral antibiotics are recommended in more severe cases (macrolides, cephalosporins, amoxicillin/clavulanate)

19. Cutaneous Fungal Infection • Tineaversicolor (caused by yeast melasseziafurfur ) • “Ringworm” (caused by dermatophytes) • Monilial (Candida infections)

22. Tineafaciei TineaCapitis

23. Treatment • Topical clotrimazole • Avoid using topical corticosteroids • Oral therapy: Fluconazole 6 mg/kg for 2 weeks Griseofulvin 20 mg/kg for 6 weeks

24. Scabies Scabies is an infestation by the itch mite, Sarcoptesscabiei. Mites are small eight-legged parasites . They are tiny, just 1/3 millimeter long, and burrow into the skin to produce intense itching, which tends to be worse at night. The mites which cause scabies are not visible with the naked eye but can be seen with a magnifying glass or microscope.

25. Signs/Symptoms • Small red papules and vesicles • Scabies may involve the webs of fingers, the wrists and the backs of the elbows, the knees, areas around the waist and umbilicus, the axillary folds, the areas around the nipples, the sides and backs of the feet, the genital area, and the buttocks. • Often there are erosions and crusting because of scratching

27. Norweigan Scabies • A severe form of scabies occuring in the context of immunosuppression • The lesions are extensive and generalized • Skin may become thickened and wart-like • Itching may be minimal or absent

28. Treatment of scabies • Topical Treatment: Permethrine • Oral treatment: Ivermectin: Dose is 200 micrograms/kg. May give a repeat dose in 2 weeks. • Antihistamines, egdiphenhydramine (Benadryl), may help provide relief from itching.

29. Permethrine (Elimite) • Applied from the neck down and washed off the next morning • Safe for children over 2 months of age

30. Treatment of scabies • Wash linens and bedclothes in hot water. Since mites don't live long away from the body, not necessary to wash all of ones clothing. • Treat sexual contacts or relevant family members (who either have symptoms or have the kind of relationship that makes transmission likely). • Cut nails, and clean under them thoroughly to remove any mites or eggs that may be present.

31. Asthma • Sx/signs: Dyspnea, cough, use of accessory muscles, wheezing • Acute management: Inhaled bronchodilator (albuterol) either by nebulizer or inhaler with a spacer • Short course of oral steroids if available • If you provide an inhaler teach technique and use spacer

33. Dysuria • UTI/ vaginitis (candida, bacterial vaginosis, trichomoniasis) • Urine dipstick • Exam if conditions allow • Avoid empiric treatment without some indication of infection

34. Vaginal Discharge • Common complaint • A scant clear or white odorless discharge is normal • Itching, burning, irritation, redness, erosions, friability are associated with infection • Character, odor of discharge may be clue to dx

36. Epigastric Pain • In patients with chronic abdominal pain H Pylori is common (62% in rural Haiti) • Treatment of H Pylori is complex and involves multiple medications-not practical • Generally we use PPIs (prilosec, nexium,etc) or H2 blockers (pepcid) or antacids in pregnant women

37. Joint/muscle pain • Hard labor • Muscle strain and DJD are common • Usually treat with ibuprofen • Use acetaminophen if older or has epigastric pain

38. Hypertension and Other Chronic Conditions • If you are at a clinic that can provide longterm follow-up and medication, provide medication per their formulary • If already on a medication and has run out try to match this drug as closely as possible • Do not give medications for chronic conditions if there is no f/u • For hypertension, CHF can advise low Na diet

39. These Global Missions are Mutually Beneficial • Provide care for people in medically underserved areas • Interact with local health professionals and students • We gain better understanding of pressures faced by people in less privileged circumstances • Often this ignites an interest in service

40. Educational Gains • See a lot of patients • Observe physical findings and diseases that you may never see at home • You use powers of observation, physical exam and common sense rather than testing to make decisions. • Learn basic pharmacology • Interact with students from other disciplines

41. Final Word of Caution • Be careful in the country • Critical care for trauma or serious illness will be limited and it will take hours to evacuate a seriously sick or injured student • If you get seriously injured or sick in the country-this can jeopardize all future trips • Consider a “ no alcohol” pledge