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2006 CHAM User Orientation

2006 CHAM User Orientation. 2006 CHAM User Orientation. Welcome and Introductions Introduce yourselves to the books Philosophy of the CHAM revision project Major changes from previous edition Introduction to the 2006 CHAM Medicine practice More scenarios. Philosophy CHAM revision project.

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2006 CHAM User Orientation

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  1. 2006 CHAMUser Orientation

  2. 2006 CHAM User Orientation • Welcome and Introductions • Introduce yourselves to the books • Philosophy of the CHAM revision project • Major changes from previous edition • Introduction to the 2006 CHAM • Medicine practice • More scenarios

  3. Philosophy CHAM revision project • Make a book that is user-friendly for the CHA/P • Also usable by physicians, trainers, supervisors • Compatible with Basic Training Curriculum

  4. Philosophy CHAM revision project • Additional information in CHAM, not included in the current Curriculum, such as: • End of Life Comfort Care • HIV patient care • Intraosseous infusion • Female cancer screening

  5. Philosophy CHAM revision project • Up-to-date standards of care • Looked at national, state, and Native health service guidelines • Cautious approach to practice • BP cutoff is 105 for Nitro • Orthostatic VS conservative • Extensive review by: • Rural Tribal Health Organization doctors who work with CHA/Ps • Medical specialists

  6. Philosophy CHAM revision project • How to Use this Book and CHAP Overview chapters contain valuable information • Explain many of the things that are new • Helpful for all users of the book • Homework assignment handout in your folder

  7. Major Changes in CHAM • Problem or chief complaint based, rather than assessment based, except chronic care. • Approach to Sick Child younger than 8 years. • Recheck section. • Emergency chapter and how it is used. • Inside Front Cover—content and clarity.

  8. Color for Navigation • Blue text • Assessment names • Section titles and breaks • Patient Ed boxes: Blue • Procedure boxes: Gray • Information for CHA/P boxes: White

  9. Telehealth • Reminder to CHA/P to use telehealth • If available • You think it will help doctor • Used in appropriate problem exam sections • Skin • Ear • Musculoskeletal • Etc.

  10. Overview of 2006 CHAM • Emergency Field Handbook • CHAM Patient Care Visit book • CHAM Medicine Handbook • Combined VMR and 1998 CHAM Medicine Chart • No more VMR • CHAM Reference and Procedure book • Laminated sheet with exams • CD ROM

  11. CD ROM • Contains all 4 volumes in PDF format • Can print any page • Click-on patient ed information that will print for CHA/P to give to patient. • Problem patient ed • Medicine patient ed

  12. CD ROM • Read the instructions carefully • Can navigate to anyplace in the 4 volumes by entering the desired page number • Does NOT contain any audio or video clips in this version

  13. How to Use the CD • Insert the disk. • Menu will pop up. • Install Adobe Reader as needed. • Do not need internet connection to do this • Takes 5 to 10 minutes to install • Will not work for Windows ’98. Call your IT department.

  14. How to Use the CD • Click on Instructions and read them carefully. • Click on CHAM 4 volume set. • Inside front cover comes up first. • May take a few minutes, depending on your computer. • To change pages: • Click on page number at bottom of screen • Enter a new page number, example: p. 290 • Press enter • P. 290 will appear

  15. How to Use the CD • To go to other books: • Reference: type in R-40. Must have R and dash • Medicine handbook: type in M-114. • Emergency handbook: type in E-36 • Now install the disk and try these steps

  16. Use the Emergency Field Handbook

  17. Scenario 1 • You are health aides in a village 250 miles from the nearest hospital. • You get a call in the middle of the night about a 4-wheeler accident with someone hurt bad. It is summer, not raining. • You arrive at the scene with your emergency kit and Emergency Field Handbook.

  18. Scenario 1 • Where do you start? • Start on p. E-1. • Scene is safe. 4-wheeler rolled over on its side several feet away from patient. One patient wearing a helmet, moaning but not moving much. Witness says he had been drinking and the 4-wheeler rolled over him. • What kind of problem: Trauma? Medical? Young child?

  19. Scenario 1 • Trauma patient. Go to p. E-5. • GA: Moaning, says stomach hurts. • Stabilize neck? • Airway and breathing: Open, breathing a little fast. • If open chest wound, would bump out here to p. E-25. Not for this patient. • Start Oxygen. • Circulation: pulse fast, weak. • No major bleeding. • Skin: normal color, cool, dry.

  20. Scenario 1 • Remove helmet: no • Rapid trauma exam: Abdomen, tender RUQ. • Weather: OK. • VS: P 120, R 20, BP 98/85. • SAMPLE history: Not cooperative to answer questions. • Treat for shock? • Experienced CHA/P might. • New CHA/P might or might not.

  21. Scenario 1 • Serious injuries: May start at • Shock p. E-11. • E-12 sends you back to E-9, then p. E-35 Assessment chart. • Abdominal Injury p. E-35. • Assessment Chart • What is Assessment? • Other Severe Abdominal Injury. • Go to p. E-41.

  22. Scenario 1 • Then go to CHAM, p. 57. • CHAM p. 66. • Back to p. E-122 for care during medevac. • The only time CHA/P is sent back to Emergency Handbook.

  23. Scenario 2 • Phone call: Says cannot wake up grandmother. Go to home with emergency kit and Handbook. • Where to start? • Start on p. E-1. • Scene is safe. • 60 year old woman lying in bed. • What kind of problem: Trauma? Medical? Young child?

  24. Scenario 2 • Medical. Go to p. E-60. • GA: Patient looks sick. Responds only to pain by moaning and moving a little. • Airway open, breathing slow and deep. • Start Oxygen. • Not exposed to cold. • Pulse slow, strong. • Skin: Pink, warm, dry.

  25. Scenario 2 • SAMPLE history: woke up during the night with a headache, but went back to sleep. Unable to wake her up this morning. No allergies or meds. High blood pressure for 2 years, didn’t want to take the medicine. • Is this Severe Allergic Reaction? • Is this a Seizure? • What next?

  26. Scenario 2 • Do blood sugar. • Blood sugar is 92. • Do vital signs. • T: 97.4; P 60; R 12; BP 160/90; SpO2 92 • Vital signs OK • Is this Poisoning, Chest Pain, Severe Shortness of Breath, Stroke, Mental Health Emergency?

  27. Scenario 2 • What next? • Rapid exam: Pupils, right larger than left, slow to respond to light. • Transport to clinic. • Report. • Go to CHAM p. 74, Additional History • Negative except for headache and hypertension.

  28. Scenario 2 • Additional Exam: neck a little stiff when flexed. Reflexes: can’t tell if they are equal. • Hgb: 12.2; No urine • What is your Assessment? • Other Cause Decreased Level of Consciousness. • Plan p. 102, Emergency 38, Other Medical Emergency

  29. Scenario 3 • A mom calls, saying her 2 month old baby is very sick. Please come to the house.  • You go with emergency kit and EFH. • Where do you start? • Start on p. E-1. • Scene is safe. • Won’t eat, very sleepy. • What kind of problem: Trauma? Medical? Young child?

  30. Scenario 3 • Go to p. E-55. • GA: pale, limp, sweaty, not moving. • LOC: difficult to wake up. • Airway open, breathing fast, shallow, grunting. • Start Oxygen. • If wheezing, could give Albuterol. • No cold exposure.

  31. Scenario 3 • Pulse 180, hard to feel. • No bleeding. • Skin feels cold, cap refill 4 seconds. • SAMPLE History • Getting sick over 2 days, won’t breastfeed or take a bottle now, was fussy and irritable, now just hard to wake up. Maybe had a fever, but now feels cold. No other symptoms.

  32. Scenario 3 • Vital signs • T 96.6; P 180; R 60, irregular; SpO2 88 • Is this Severe Allergic Reaction? • Is this Seizure? • What next? • Check blood sugar • Blood sugar 68 • Examine quickly • Eyes sunken, mouth dry • Chest clear. Abdomen soft.Arms/legs: floppy, limp

  33. Scenario 3 • Is this Poisoning? • Is this child very sick? • Yes • Very sleepy, will not drink • Looks very sick, pale • Vital signs: T 96.6; P 180; SpO2 88 • Eyes sunken, mouth dry • Floppy, limp • Skin cold; cap refill 4 seconds

  34. Scenario 3 • Transport to clinic • What next? • Very sick child. Go to CHAM p. 149 • Follow Plan 1 while trying to contact doctor

  35. Look through Emergency Handbook • New volume. For use by health aide who has completed Session I and ETT. • Designed to be used outside the village clinic. All plans send CHA/P to CHAM for continued care in clinic. • Layout and content are similar to emergency chapter in CHAM. • Tabs for major sections.

  36. Emergency Handbook • Information for giving emergency medicines is in this book. • p. E-74, 75 • Section for Emergency Childbirth. • Skills summary. • Plan “Care of Patient During Medevac”, p. E-122; written plan to follow during transport.

  37. CHAM Patient Care Book • Look at Dedication • Look at Table of Contents, p. 10 and 11 • Chapters organization • Emergency • Emergency Childbirth • Child • Elders • Head; Chest; Abdomen; Musculoskeletal, Skin/Soft Tissue • Urinary, Male, Female, Pregnancy • Nervous; Endocrine; Immune • Mental Health; Alcohol/Drug; Other Topics.

  38. CHAM Patient Care Book • Always try to go forward in the book, not backwards. Less skipping here andthere. Plans may be repetitive to avoid going to another section.

  39. CHAM Patient Care Book • Children: In order to identify early and as often as possible the very sick child, CHAM is designed to catch the very sick child at a number of places in the patient visit.

  40. CHAM Patient Care Book • Look at Digestive Chapter, p. 359 • Do Not begin here, Begin Here • Problem sections in order • Injury, Acute, Chronic • History: Most Other History is gone, was incorporated into HPI. • If not already done • Standard questions for child younger than 3 years. • Exam: Sick Child box if problem may involve a child. To eliminate the need for multiple chapter histories and exam. • If not already done

  41. CHAM Patient Care Book • Assessments: • Some chapters have 2 assessment charts. Look at Assessment step for instructions. • Female, p. • Musculoskeletal, p. • Skin/Soft Tissue, p. • Possible vs definite. Medicaid issues. • Assessment charts or lists of assessments for that problem. • Example: Breast problems Assessment, p. 512. A list rather than a chart • May or may not definition

  42. CHAM Patient Care Book • Assessment charts and lists try to cover the most common findings for the problems. • Definitive assessments are those that a health aide can make using the CHAM and lab tests available in the village. • There is extensive use of the word “possible” • In order of most common or most urgent

  43. CHAM Patient Care Book • Plans • Plan names: Eye, Eyelid; Child, Teen; Mouth, Jaw, Teeth • Definitions after plan name • Generally follow a standard format. • May have immediate or emergency care. Any change in order of steps was deliberate. • New sections: While or If waiting to transport

  44. CHAM Patient Care Book • Standing Orders: Many changes. Old ones gone, new ones possible. All marked; p. 624 • Employer may issue other standing orders, but are responsible for testing, etc. • Medicines NOT part of standing order: p. 304 • Special Topics and Procedure Summaries mostly gone. • Most procedures are in Reference/Procedure book.

  45. Inside Front Cover • There are 7 different places to go from Inside Front Cover.

  46. Scenario 4: Emergency • Adult male walks into clinic. Looks pale, says he feels very sick and needs to lie down. • As you start to get him onto exam table, he faints. • Where to start in CHAM? • Inside Front Cover: Emergency, go to p. 40. • Scene Size-up • No apparent injury. He said he felt sick. • What kind of problem: Trauma? Medical?

  47. Scenario 4: Emergency • Medical Emergency Adult: go to p. 72. • Looks like emergency field handbook • Differences from handbook • References to cold weather care • Transport to clinic • Plans are expanded to include medicines and more detailed care in clinic while waiting to talk to doctor.

  48. Scenario 4: Emergency • Patient wakes up enough to tell you he has had chest pain and felt faint for about 2 hours. • Follow steps to Chest Pain listing on p. 73. • Go to p. 90. • Emergency care, if not already done. • Get history, exam. • You decide Assessment is Chest Pain, Possible Heart Attack. • Go to p. 95, Plan Emergency 33 while trying to contact doctor.

  49. Scenario 4: Emergency • What medicine should you give? • ASA and Nitroglycerin • Morphine, ONLY after talking to doctor • What additional care? • Start an IV • While waiting to transport • Recheck vital signs • Continue this plan • Go to p. 102, Emergency 38, Care of Patient While Waiting for Medevac

  50. Scenario 5: Sick Child Younger than 8 Years • 2 year old comes in fussy, fever, pulling at left ear, runny nose, cough. • Inside front cover to p. 1. • Box Young Child Who May be Very Sick • Child has none of those findings. • Back to Inside Front Cover Begin History

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