1. Changing Your Frame of Reference Standards of Care in HA Operations

2. “Two Standards of Care” w Understand “Two Standards of Care” w Empiricism - relying on hunches more than hard data w Medical Supplies WHO Emergency Health Kit

3. The Non-U.S. Standard of Care w Other people have the same values, morals, ethics w They lack the same resources $8 per person per year

4. Who Provides Health Care? w Nurses and community health workers w Little to no supervision by a physician w 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

5. The Best Thing for Medical w Training Others to perform medical tasks is the most valuable use of our time Oral rehydration Health education Disease surveillance

6. Who is Treated? w No extraordinary measures w 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?

7. How do you treat? w IV therapy is extraordinary treatment expensive (man-hours, sterile supplies) w Greater reliance on oral and intramuscular medications w Convenience and ease of administration are forsaken for cost and durability of medicines w No lab or X-ray; no time for in-depth diagnosis (up to 60-100 patients per day per doc)

8. What is Used to Treat? w No comfort meds (cold and cough remedies) w Low cost, low glamor antibiotics

9. Strive Hard to Maintain the Two Standards of Care w Do not stir up ethnic strife by inadvertant favoritism w Do not make the refugees more unwelcome than they already are by exceeding the standard of care of the host country w Don’t set a standard you can’t sustain w Set a policy for civilians/refugees injured by USMC activities

10. The WHO Emergency Health Kit w Developed by UNHCR, London School of Tropical Medicine, UNICEF, Doctors without Borders, International Red Cross) w Driven by prior failures w Reliable, standardized, proven, durable, inexpensive, appropriate w Packaged for durability (can be air-dropped) w Inventory used as model for whole nations’ drug supplies

11. WHO Kit Set-up w Designed to support 10,000 patients for 3 months w 10 Basic Units: oral and topical medicines w 1 Supplementary Unit: injectables 1000 10,000 1000

12. Specialized Kits w Measles Vaccination Cold-Chain Kit 5000 immunizations

13. Supplies in the WHO Kit (selected list) w Antibiotics (very basic) w Oral Rehydration Salts w Pressure Sterilizer w Kerosene Stove w Weight / Height Charts w Clinical Guidelines

14. The Antibiotics w Penicillin V w Penicillin G IM w Penicillin G IV w Ampicillin w Septra w Chloramphenicol w Tetracycline

15. Penicillin V w 250 mg tabs (4000) child 25 - 50 mg / kg / d divided q 6-8 h adult: 1 tab po qid w Indications Minor respiratory head and neck infecitons oral anaerobes, group A strep

16. Penicillin G and Bicillin IM w Procaine IM only(1000 doses) child: 25-50 k units / kg / d divided q 12 h adult: 300 - 600 k units q 12 h w Bicillin (50 doses) depot shot q 15-30 days w Indications Mild-moderate versions of: respiratory infections head & neck infections oral anaerobes, strep

17. Ampicillin PO / IM / IV w Ampicillin PO(2000 tabs) child: 50 - 100 mg / kg / d divided q6h adult: 2 - 4 g / d divided q6h w Ampicllin IM / IV (200 doses) child: 100 - 400 mg / kg / d divided q4-6h adult: 6 - 12 g / d divided q4-6h w Indications moderate-severe respiratory infections neonatal sepsis / meningitis better gram-negative coverage than PCN

18. Septa w 80 TMP / 400 SMX tabs ORAL (20,000 doses) child: 8 - 12 mg TMP /kg/d divided BID adult: 1 - 2 tabs PO bid w Indications: mild-moderate respiratory conditions skin infections UTI cholera and dysentery w Watch out for sulfa allergy and bone marrow suppression

19. Chloramphenicol w Oral: 250 mg tabs (2000 doses) w IM / IV1 g injections (500 doses) w 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

20. Chloramphenicol continued w Indications Excellent penetration of all body fluids Use for all serious infections sepsis meningitis respiratory infections bone / joint infections typhoid, cholera, dysentery

21. Excellent Bioavailability of Chloramphenicol

22. Toxicity of Chloramphenicol w Reversible dose-dependent bone marrow suppression w Aplastic anemia (1:40,000 recipients) occurs weeks to months later not dose related w Gray Baby Syndrome overdosing in infants --> flaccidity, cyanosis w Hemolytic anemia in G6PD deficiency

23. Tetracyline w PO: 250 mg (2000 doses) child: 25 - 50 mg/kg/day div q6h adult: 250-500 mg q6h w Indications: mild-moderate respiratory infections cholera, dysentery, malaria w Toxicity stains young teeth: don’t give to pregnants or kids < 8 yrs/ old