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)

PneumococcalResistance

20 % 5 %

Cost per personper treatment

$ 1 $ 100

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

10,000

1000 1000 1000 1000 1000

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

0

2

4

6

8

10

12

14

0 1 2 3 4 5 6 7 8Hours

Pla

sma

Lev

els

POIMIV

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