Transcript Changing Your Frame of Reference

Changing Your Frame of Reference
Standards of Care in HA Operations
“Two Standards of Care”
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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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Other people have the same values, morals,
ethics
They lack the same resources
• $8 per person per year
Who Provides Health Care?
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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
The Best Thing for Medical
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Training Others to perform medical tasks is
the most valuable use of our time
• Oral rehydration
• Health education
• Disease surveillance
Who is Treated?
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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?
How do you treat?
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IV therapy is extraordinary treatment
• expensive (man-hours, sterile supplies)
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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)
What is Used to Treat?
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No comfort meds (cold and cough
remedies)
Low cost, low glamor antibiotics
DRUG
PENICILLIN
ROCEPHIN
(high-speed,
low-drag)
Pneumococcal
Resistance
20 %
5%
Cost per person
per treatment
$1
$ 100
Strive Hard to Maintain the Two
Standards of Care
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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
The WHO Emergency Health Kit
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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
WHO Kit Set-up
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Designed to support 10,000 patients for 3
months
10 Basic Units: oral and topical medicines
1 Supplementary Unit: injectables
1000
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10,000
Specialized Kits
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Measles Vaccination Cold-Chain Kit
• 5000 immunizations
Supplies in the WHO Kit
(selected list)
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Antibiotics (very basic)
Oral Rehydration Salts
Pressure Sterilizer
Kerosene Stove
Weight / Height Charts
Clinical Guidelines
The Antibiotics
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Penicillin V
Penicillin G IM
Penicillin G IV
Ampicillin
Septra
Chloramphenicol
Tetracycline
Penicillin V
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250 mg tabs (4000)
• child 25 - 50 mg / kg / d divided q 6-8 h
• adult: 1 tab po qid
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Indications
• Minor respiratory
• head and neck infecitons
• oral anaerobes, group A strep
Penicillin G and Bicillin IM
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Procaine IM only
(1000 doses)
• child: 25-50 k units / kg / d divided q 12 h
• adult: 300 - 600 k units q 12 h
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Bicillin (50 doses)
• depot shot q 15-30 days
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Indications
• Mild-moderate versions of:
• respiratory infections
• head & neck infections
• oral anaerobes, strep
Ampicillin PO / IM / IV
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Ampicillin PO
(2000 tabs)
• child: 50 - 100 mg / kg / d divided q6h
• adult: 2 - 4 g / d divided q6h
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Ampicllin IM / IV (200 doses)
• child: 100 - 400 mg / kg / d divided q4-6h
• adult: 6 - 12 g / d divided q4-6h
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Indications
• moderate-severe respiratory infections
• neonatal sepsis / meningitis
• better gram-negative coverage than PCN
Septa
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80 TMP / 400 SMX tabs ORAL (20,000
doses)
• child: 8 - 12 mg TMP /kg/d divided BID
• adult: 1 - 2 tabs PO bid
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Indications:
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mild-moderate respiratory conditions
skin infections
UTI
cholera and dysentery
Watch out for sulfa allergy and bone
marrow suppression
Chloramphenicol
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Oral: 250 mg tabs (2000 doses)
IM / IV 1 g injections (500 doses)
Doses:
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< 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
Chloramphenicol continued
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Indications
• Excellent penetration of all body fluids
• Use for all serious infections
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sepsis
meningitis
respiratory infections
bone / joint infections
typhoid, cholera, dysentery
Excellent Bioavailability of
Chloramphenicol
14
12
Plasma Levels
PO
IM
IV
10
8
6
4
2
0
0
1
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4
Hours
5
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8
Toxicity of Chloramphenicol
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Reversible dose-dependent bone marrow
suppression
Aplastic anemia (1:40,000 recipients)
• occurs weeks to months later
• not dose related
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Gray Baby Syndrome
• overdosing in infants --> flaccidity, cyanosis
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Hemolytic anemia in G6PD deficiency
Tetracyline
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PO: 250 mg (2000 doses)
• child: 25 - 50 mg/kg/day div q6h
• adult: 250-500 mg q6h
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Indications:
• mild-moderate respiratory infections
• cholera, dysentery, malaria
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Toxicity
• stains young teeth: don’t give to pregnants or
kids < 8 yrs/ old