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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

Changing Your Frame of Reference

Standards of Care in HA Operations

two standards of care
“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
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
who provides health care
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
the best thing for medical
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
who is treated
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?
how do you treat
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)
what is used to treat
What is Used to Treat?
  • No comfort meds (cold and cough remedies)
  • Low cost, low glamor antibiotics
strive hard to maintain the two standards of care
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
the who emergency health kit
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
who kit set up
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

specialized kits
Specialized Kits
  • Measles Vaccination Cold-Chain Kit
    • 5000 immunizations
supplies in the who kit selected list
Supplies in the WHO Kit(selected list)
  • Antibiotics (very basic)
  • Oral Rehydration Salts
  • Pressure Sterilizer
  • Kerosene Stove
  • Weight / Height Charts
  • Clinical Guidelines
the antibiotics
The Antibiotics
  • Penicillin V
  • Penicillin G IM
  • Penicillin G IV
  • Ampicillin
  • Septra
  • Chloramphenicol
  • Tetracycline
penicillin v
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
penicillin g and bicillin im
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
ampicillin po im iv
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
septa
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
chloramphenicol
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
chloramphenicol continued
Chloramphenicol continued
  • Indications
    • Excellent penetration of all body fluids
    • Use for all serious infections
      • sepsis
      • meningitis
      • respiratory infections
      • bone / joint infections
      • typhoid, cholera, dysentery
toxicity of chloramphenicol
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
tetracyline
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