StandardsofCare by veeru5656

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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
   Other people have the same values, morals,
    ethics
   They lack the same resources
    • $8 per person per year
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
   Training Others to perform medical tasks is
    the most valuable use of our time
    • Oral rehydration
    • Health education
    • Disease surveillance
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?
   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?
   No comfort meds (cold and cough
    remedies)
   Low cost, low glamor antibiotics
      DRUG            PENICILLIN   ROCEPHIN
                                   (high-speed,
                                    low-drag)

    Pneumococcal        20 %          5%
     Resistance


    Cost per person      $1          $ 100
     per treatment
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
   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
   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
   Measles Vaccination Cold-Chain Kit
    • 5000 immunizations
Supplies in the WHO Kit
       (selected list)
   Antibiotics (very basic)
   Oral Rehydration Salts
   Pressure Sterilizer
   Kerosene Stove
   Weight / Height Charts
   Clinical Guidelines
The Antibiotics
   Penicillin V
   Penicillin G IM
   Penicillin G IV
   Ampicillin
   Septra
   Chloramphenicol
   Tetracycline
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

   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         (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
   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
   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
   Indications
    • Excellent penetration of all body fluids
    • Use for all serious infections
       •   sepsis
       •   meningitis
       •   respiratory infections
       •   bone / joint infections
       •   typhoid, cholera, dysentery
Excellent Bioavailability of
Chloramphenicol
     14
     12                                         PO
                                                IM
Plasma Levels




     10
                                                IV
            8
            6
            4
            2
            0
                0   1   2   3     4     5   6        7   8
                                Hours
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
   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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