Download 2014 Leon Haiti Mission Medical Guidelines Revision Summary Information Page

2014 Leon Haiti Mission Medical Guidelines
Revision Summary Information
Page
Number
Changes
Date
3
3
Updated information on medical emergencies and referral
Updated information about Gebeau and X-Rays and unavailability of CT/MRI in Grand’Anse; updated
diagnostic test info for HHF and to remove info duplicated in Lab User Guide.
Water: Comment added about how chlorination of the Leon public water source has been discontinued and
the importance of education on disinfecting all water used in drinking/cooking.
Added information about standard chronic disease medicine dispensing being a one month supply and how
it is important for providers to remind patient to return monthly for rechecks with local nurse and refills
Added azithromycin to the formulary
Removed docusate from the formulary
Removed multivitamins from the formulary. To be consistent with other organizations practicing in the
Grand’Anse, multivitamins will no longer be routinely provided. (Prenatal vitamins are still available.)
Added dosing information for ketamine in procedural sedation
Updated Ivermectin dosing information based on information received from the supplier
Updated iron/folate product information. Ferrovite is no longer used and has been replaced by generic
iron/folic acid tablets.
Added information about only providing an inhaler to patients actively wheezing when at clinic
Removed reference to dispensing five months of hypertension meds: Standard quantity is now one month of
meds
Updated vaginitis treatment guidelines: For diabetic patients with vaginitis, treat for candida as well. For
women 16-31 with vaginitis, treat for GC/CT as well as BV/Trich. (Removed reference to douching.)
Updated GC/CT guidelines for men. There is a high prevalence of T. vaginalis in the Grand’Anse. Men
should also be treated for TV when treating for GC/CT
Updated GC/CT guidelines: Women 16-31 with vaginitis should also be treated for GC/CT. Added comment
about azithromycin is preferred treatment for CT as it allows for one-time DOT in clinic and also covers M.
genitalium.
Clarified interpretation information for Anti-TP positive and Non-TP negative syphilis tests.
Updated referral information, criteria and example forms throughout document.
Added explanation about rationale for ferritin test add on when Hgb is >10.5 g/dL in non-pregnant women
18-35
Dec 2013
4
6
6
N/A
N/A
8
8
9, 21
12
N/A
15
15
15
16
Multiple
20
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 1 of 33
Dec 2013
May 2013
May 2013
May 2013
Dec 2013
Dec 2013
Dec 2013
Mar 2014
Dec 2013
Dec 2013
May 2013
May 2013
Dec 2013
May 2013
Feb 2014
Dec 2013
Feb 2014
Updated: March 27 2014
TABLE OF CONTENTS
Introduction
Page 3
Medical Emergencies
Page 3
Diagnostic Tests
Page 3
Elective Clinic Procedures
Page 4
Public Health Education
Page 4
Medical Records
Page 5
Disease Management Cards
Page 5
Palliative and End of Life Care
Page 5
Pharmacy and Formulary
Page 5
Treatment Guidelines
Page 10
Medical Referrals
Page 23
Persons Outside Leon Area
Page 29
Hospitalizations
Page 29
Diabetes Treatment Algorithm
Page 30
Sample Forms
Page 31
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 2 of 33
Updated: March 27 2014
INTRODUCTION
These guidelines are not meant to be comprehensive treatment plans or inclusive of all conditions. Guideline should be
modified for individual patients. Practitioners are expected to practice within the scope of their U.S. professional licenses.
The goals of treatment in Leon are to respect culture, relieve suffering, promote health and do no harm. Care provided
must be integrated into the local system of health. Traditional healthcare must be respected.
MEDICAL EMERGENCIES
There will generally be a couple of serious emergencies during a two week mission. In the past, these have included
status epilepticus, fractures, serious lacerations, acute respiratory arrest, acute CVAs and car accidents. Supplies and
medications to handle these situations are limited. Practitioners need to be practical, sensitive and creative in determining
the best management of these emergencies. Advanced life support is generally not possible and not expected. Consult
with team leader and experienced providers before referring. It may be better to manage patient in the clinic and have
them return for follow up. Services at Hospital San Antoine are unreliable and often unavailable. Patients have been
referred to HSA and not seen for >12 hours.
DIAGNOSTIC TESTING
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Portable ultrasound is brought with the team. Ultrasound is also available at HHF on Tuesday and Wednesday.
Radiology is not available in Leon. Closest is at hospital in Jérémie or at Gebeau. Patients may be referred to
Gebeau for an x-ray and instructed to bring the film back to Leon for reading.
CT and MRI are not available in the Grand’Anse.
The laboratory at the hospital has limited capacity and only during the daytime hours.
Patients can get laboratory work Monday through Friday at the HHF Centre of Hope for a fee. Lab services at HHF
include limited chemistry, hematology and microbiology testing, serology (HIV, syphilis and pediatric HIV RNA test
sendout), urinalysis, bleeding/clotting times, Hgb A1c and Pap smears. No coagulation testing (other than bleeding
times), thyroid testing or other endocrine testing is available.
There is an HIV treatment program at the hospital where patients can get HIV testing and CD4 counts.
Blood “banking” is restricted to typing and direct whole blood transfusions. If a patient is likely to need transfusion
(HGB < 5 g/dL), have several family members go with the patient so that they are available to provide blood for the
patient.
Refer to the Laboratory User’s Guide for detailed test information and test algorithm information.
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 3 of 33
Updated: March 27 2014
ELECTIVE CLINIC PROCEDURES
Many patients will present with conditions that would be easily corrected such as lipoma, nodules, polydactyly and various
cysts. However, elective procedures should be carefully considered taking into account patient flow in the clinic, limited
sterile supplies and lack of a clean procedure area. Before attempting an elective procedure, the provider should
consult with a second experienced provider.
PUBLIC HEALTH EDUCATION
Public health messages are strongly encouraged to prevent disease and promote health. The messages we deliver are
harmonized with those provided through HHF and the Provincial Ministry of Health. The messages are emphasized with a
small incentive to reinforce the message.
Public Health Incentives
Potable water
Breastfeeding
Finger nail clipper and or nail
file
Soap and washcloth
Toothbrush and paste
Beans and rice
Skin cream
Akamil
Immunizations
Public Health Message
In January 2012 the water in the Leon pipes was tested and found to be safe.
Reports in February 2013 indicate that chlorination of the public water
cistern/supply has been discontinued. Additionally, many patients in outlying
areas still rely on water from untreated water sources. Patients should be
educated on the importance of always disinfecting water used in drinking and
cooking.
All women should breastfeed as long as possible, (even if HIV positive) during the
first year of life. Exclusive breast feeding until 6 months of age, followed by
breastfeeding until two years of age with complementary foods.
Trim your child’s nails to keep them clean to prevent skin infections and diarrhea.
Keeping your hands clean helps to prevent infection.
Clean teeth daily to keep a beautiful smile and prevent decay.
Two parts rice and one part beans cooked together makes a complete protein to
promote growth.
Care for your skin to prevent infections and rashes.
More nutritious and less expensive way to feed your family.
Immunize your children. There are several vaccination clinics done throughout
the villages by HHF and the MOH. Ask parents about the vaccination status of
their child and reinforce the importance of vaccination.
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 4 of 33
Updated: March 27 2014
MEDICAL RECORDS
Brief documentation of patient encounters is to be done in the patient’s Leon Dispensary medical chart including
diagnosis, key exam and laboratory findings, medications and referral if provided.
There are national child health cards and prenatal care cards. These should be requested for all children and pregnant
women. After entering the medical information, they should be returned to the mother. Once the encounter is complete,
the patient takes his dossier to the pharmacy and receives his/her medications.
DISEASE MANAGEMENT CARDS
All patients with diabetes, seizure disorder, hypertension or other conditions that require ongoing management are given a
Disease Management Card. This card is printed on hard-stock paper, and is stored in a plastic zip-lock bag. It contains
the patient’s medications and pertinent lab tests. It is to be brought by the patients to ALL medical encounters at the Leon
Dispensary or anywhere else that the patient receives medical care. (e.g., HHF, Gebeau, other intermittent medical
mission).
PALLIATIVE AND END OF LIFE CARE
It is not uncommon for patients to be seen in the clinic who are clearly dying. In general, if you expect the patient to die it
is better not to refer the person to the hospital but to keep him or her comfortable in Leon. The community understands
that death is a natural part of life and would rather not have the person die in Jérémie, making it difficult for them to be
with the person and then need to transport the remains back to Leon.
PHARMACY
Team members are requested NOT to bring any medicines unless they are on the formulary or otherwise
authorized by the team leader.
Due to irregular and unpredictable shortages of medications, there may be changes to the formulary with each mission.
This is a reality of life in Haiti.
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 5 of 33
Updated: March 27 2014
The pharmacy is staffed with either a Haitian nurse or pharmacist. Do not rely on these professionals to calculate doses.
Be specific in your written orders, and if it is a unique situation, go to the pharmacy and personally explain you orders
through a translator. For routine medications (acetaminophen, ibuprofen, antacids) the pharmacy staff will dispense
accordingly in a standard dosing. Chronic disease (diabetes, hypertension) medications are dispensed for thirty days at a
time. Instruct the patient to return to the clinic every month for a recheck with the local nurse and a medication
refill. When possible Directly Observed Therapy (at the provider station) is preferred for single dose therapies (i.e., STI
meds, oily iodine capsules).
We carry fentanyl, morphine, diazepam, midazolam and an oral pain medication (Vicodin or oxycodone). They are
primarily meant for team members in case of serious injury. However, they can be used for severe pain in our patients.
Examples include painful procedures in the clinic, acute fractures and patients who are near end of life. In addition, we
have ketamine for procedural sedation (dose is 0.5-1 mg/kg IV repeated as needed).
FORMULARY
Medication
Albendazole
Salbutamol (Albuterol) Inhaler
Amoxicillin
Antacid (preferably Calcium based)
ASA (rarely used)
APAP
Azithromycin
Benzyl Benzoate (scabicide)
Ceftriaxone
Cephalexin
Dosage
Adults:400mg (1 tab)
Peds:, ≤1y.o. 100mg (1/4 tab); 1-2y.o. 200mg (1/2 tab); >2y.o. 400mg (1 tab)
Adult:2 puffs qid
Peds:2 puffs qid
Adult:250-500 mg tid
Peds:40-80 mg/kg/day
Adult: prn
Peds: generally not indicated
Adult:325mg 1-2 qid
Adult: 81mg/day for CVA and MI prevention with comorbidities (previous CVA,
HTN)
Peds: not indicated
Adult:325mg 1-2 qid
Peds:10-15mg/kg/dose qid
Adult: 1gm po now (also remember to treat partners, as applicable)
Used for pregnant women and infants
Adult:250-1000 mg IM
Peds:50mg/kg IM
Adult:250-500mg qid
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 6 of 33
Updated: March 27 2014
Medication
Dosage
Peds:50 mg/kg/day qid
Chloroquine Phosphate 250 mg
(150 mg base)
Cimetadine
Ciprofloxacin
Dexamethasone
Diphenhydramine
Doxycycline
Enalapril
Erythromycin
Erythromycin Ophthalmic
Ointment/Drops
Folic Acid
Fluconazole 150mg
Furosemide (40 mg)
Gentamycin ophthalmic drops
Glipizide
Griseofulvin
Glyburide
Hydrocortisone 1% cream
Hydrochlorothiazide
Ibuprofen
Adult:1gm po 1, 500mg in 6 hours, then 500mg qd 2days
Peds:10mg base/kg*1, 5mg mg/kg in 6 hours, then 5mg base/kg qd for 2 days
Adult:400mg bid
Peds:20-40 mg/kg/day bid
Adult:250-500mg bid
Peds: Complicated UTI and Pyelonephritis dose 20-40mg/kg/day divided BID
Peds: .6mg/kg (can use IV solution po)
Adult: 10 mg
Adult:25-50mg qid
Peds:1mg/kg qid
Adult:100mg bid
Peds: contraindicated
Adult: 5-20 mg daily
Adult:250-500mg qid
Peds:40mg/kg/day (qid)
Adult: qid
Peds: qid
Use for pregnant women and anemia
Adult: RDA: 500 micrograms daily for breastfeeding adult women; 600
micrograms daily for pregnant adult women.
Adult: 150mg (as indicated for the type of infection)
Peds: 3 mg/kg (as indicated for the type of infection)
Adults: For congestive heart failure.
Adult and Peds: qid
Adults: 5-40 mg/day
Adult: 330mg UM tab qd
Peds: 20-25 mg/kg (Tinea Capitus 6-12 weeks)
Adults: 2.5 – 20 mg/day
Adults and Peds: 2-3 x daily prn
Adult: 12.5 – 50 mg
Adult:400-600mg tid
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 7 of 33
Updated: March 27 2014
Medication
Iodine (in oil) Yodiol (200mg capsules)
Iron Supplementation
Ferrous Sulfate (60 mg essential iron,
250 mcg Folic Acid
Haemoplex Syrup (38 mg elemental
per teaspoon)
Ivermectin 6 mg tablets
(0.2 mg/kg)
Ketamine
Ketoconazole
Metformin
Methyldopa
Metronidazole
Miconazole cream
Neosporin or Bacitracin Ointment
Nystatin suspension
Penicillin (Benzathine) 2.4 million U
injectable
Prenatal Vitamins
Polymixin B and Neosporin and
Hydrocortisone Ear Drops
Prednisone
Ranitidine
Dosage
Peds:5-10mg/kg/dose (q4h)
Adult: Treat pregnant women with 400 mg (two tabs) as DOT
*Folic acid supplementation for all anemic patients is recommended by WHO.
Adult: Hemoglobin less than 7, one Iron/Folate bid for three months
Hemoglobin 7-10.5, two Iron/Folate daily for three months
Peds: Less than two years of age: 25 mg essential iron per day for three months
Over two years of age: 60 mg essential iron per day for three months
1/2 tab age 1-3
1 tab up to 30 kg age 3-8
2 tabs 30-60 kg (most adult Haitians)
3 tabs over 60 kg
Adult and Peds: .5-1mg IV, may repeat as needed for sedation (Practitioner
must be familiar with procedural sedation and nurse must monitor until awake.)
Adult: 200-400 mg qd
Peds: 3.3-6.6 mg/kg/day
Adult: 500 mg qd to 1000 mg bid
Adult:250-500mg qd, bid, or tid
Adult:500mg tid ; STI and Vaginitis single dose RX 2 grams DOT
Peds:30mg/kg/day (tid)
Adult and Peds:tid
As directed
Adult and Peds:1 ml qid
Adults: 2.4 mil U IM weekly for three consecutive weeks for all syphilis
Adult: qd
Adult and Peds:3 gtts qid
Adult: as prescribed
Peds: 2mg/kg/day
Adult:150mg bid
Peds:4-5mg/kg/day bid
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 8 of 33
Updated: March 27 2014
Medication
Sulfacetamide ophthalmic drops
Tegretol 200mg
Terazosin 1 mg and 5 mg
TMP-SMX (single strength tabs)
Dosage
Adult and Peds: qid
Adult: 200 – 600 mg bid
Children: 10-20 mg/kg/day in twice day dosing
Adult: 1-5 mg daily
Adult:2 tablets bid
Peds:5mg TMP/kg bid or for suspension 0.5ml/kg bid
Non-formulary Medications
There are some ‘non-formulary” medications that are not used often, but are very important in unique situations. The
medical teams will try to maintain a small cache of these drugs:
Non-Formulary
Critical Medications
Sub-lingual nitroglycerine
Beta blocker for acute MI
Diphenhydramine
Epinephrine
Intravenous furosemide
Intravenous quinine
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 9 of 33
Updated: March 27 2014
TREATMENT GUIDELINES
Patients present with many complaints at a single visit. Many of these complaints are long standing issues, and are not
associated with any serious medical condition. Patients expect to receive medications such as OTC pain medications and
antacids.
Initiation of chronic pharmacological therapy should be done only when the practitioners have reasonable assurance that
ongoing monitoring of care will be accomplished. There is a nurse permanently assigned to the Leon dispensary,
sometimes physicians at the Jérémie hospital and village health workers through the Haitian Health Foundation (HHF)
that may be available to provide ongoing care. HHF village clinics do not provide ongoing management of chronic
disease.
Diagnosis
Syndrome
Primary Treatment
Alternative
Treatment
HEENT
Headache
Conjunctivitis
Conjunctivitis
Inclusion (Trachoma)
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History
R/O infection
R/O dental caries
R/O vision problem
Red conjunctiva
Purulence
No eyeball pain
Vision OK
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Swollen conjunctiva
Cobblestoned
conjunctiva
Corneal Scarring
Mainly adults and teens
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2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Peds: APAP
Peds: Ibuprofen
Adults: APAP
Adults: Ibuprofen
Neonates: (assume GC/Chlamydia)
ceftriaxone and erythromycin
ointment
Peds: Erythromycin
(oral)
Peds and Adult: Erythromycin,
Gentamycin, or Sulfa ointment or
drops
Peds: Erythromycin (oral and
ophthalmic ointment)
Adult: Erythromycin or
doxycycline (oral)
Adults: Tetracycline
(oral and ophthalmic
ointment)
Adults: Erythromycin (oral and
ophthalmic ointment)
Page 10 of 33
Updated: March 27 2014
Diagnosis
Syndrome
Primary Treatment
Otitis Media
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Ear pain
Diminished hearing
Red and/or dull TMs
Peds and Adults: Amoxicillin
Otitis Externa
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Ear pain
Swollen EAC and
drainage
Peds and Adults:
Polymixin/Neosporin/hydrocortisone
drops or other antibiotic ear drop
Sinusitis
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14 days duration
Purulent nasal
discharge
Facial pain
Headache
Rhinorrhea (clear)
Sneezing
Conjunctiva edema
Seasonal
Rhinorrhea
Sneezing
Coughing
Low grade fever
Sore throat
Exudate
Tonsil enlargement
Fever
White patches on oral
mucosa
Primarily infants
Peds and Adults: Amoxicillin
Allergic rhinoconjunctivitis
Viral URI
Acute pharyngitis
Oral Moniliasis
(Thrush)
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2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Alternative
Treatment
Peds: Ceftriaxoine or
TMP-SMX
Adults: TMP-SMX or
erythromycin
Peds and Adults:
Consider adding oral
amoxicillin or
erythromycin
Peds and Adults:
TMP-SMX
Peds: Diphenhydramine
Peds: Loratadine
Adults: Diphenhydramine
Adults: Loratadine
Peds: Oral rehydration
Peds and Adults:
APAP and
diphenhydramine
Adults: Oral rehydration
Peds: Amoxicillin
Peds and Adults:
Erythromycin
Adults: Amoxicillin
Peds: Diflucan
Adults: Diflucan (consider HIV)
Page 11 of 33
Peds and Adults:
Fluconazole or
Ketoconazole
Updated: March 27 2014
Diagnosis
Syndrome
Primary Treatment
Alternative
Treatment
RESPIRATORY
SYSTEM
Bronchitis
Asthma
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Productive cough
Fever
Rhonchi that clear with
coughing
Intermittent and
reversible wheezing
Peds: Bactrim
Adult: Erythromycin/doxycycline
Peds or Adults: TMPSMX or doxycycline in
adults.
Peds :Albuterol Inhaler, prednisone
1-2 mg/kg or dexamethasone .6
mg/kg 3 days
Adult and Peds:
Subcutaneous
epinephrine if severe.
Adults: Albuterol inhaler, prednisone
Albuterol inhalers are
highly desired
medications. The
inhalers “disappear”
quickly. They are
also hard to find in
Haiti.
Only give an inhaler when the
patient is actively wheezing during
the exam.
Bronchiolitis
Pertussis
Pneumonia
Tuberculosis
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Less than 5 y.o.
Expiratory wheezing
Single occurrence
Cough for over 2 weeks
Whooping cough
Afebrile
Fever
Cough
Tachypnea
Chest pain
Peds: Oral rehydration
Consider albuterol
inhaler
Peds and Adults: Erythromycin for
14 days
Adults and Peds:
Azithromycin
Neonate: Refer to hospital or
consider ceftriaxone for 3 days
Peds: Bactrim
Adult: Erythromycin
Adult or Peds:
Consider ceftriaxone
if severe.
Adults: Doxycycline or
amoxicillin

Productive and
persistent cough
Refer to TB program at the clinic
(Jean Claude)
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 12 of 33
Updated: March 27 2014
Diagnosis
Syndrome
Primary Treatment
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Fever/Night Sweats
Hemoptysis
Congestive Heart Failure
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Peripheral edema
Rales
Orthopnea/Dyspnea
Furosemide
Enalapril
Nitrates, if available
Hypertension (mild and
moderate)
Hypertension (severe)
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BP < 180/110
BP > 140/90
BP > 180/110
Adults: Low salt diet
Recheck BP with local provider
Adults:
HCTZ 12.5-25 mg qd
Enalapril 5-40 mg qd
Amlodipine 5-10 mg/day
Intestinal parasites
(pinworms, Ascariasis,
hookworm)
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Asymptomatic
Decreased appetite
Wheezing
Worms seen
Albendazole
“Acide”
a.k.a. Dyspepsia
(mild and moderate)
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Intermittent heartburn
“Acide”
Dyspepsia (severe)
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Daily epigastric pain
One month or more in
Alternative
Treatment
CARDIOVASCULAR
SYSTEM
Refer for
hospitalization if
severe an cannot be
managed on diuretic
and ACE inhibitor.
Encourage follow-up
monthly with the local
Haitian nurse and at
the regular mission
visits.
GASTROINTESTINAL
SYSTEM
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
(Patients will receive worm meds in
triage except children under one
year and pregnant women in the
first trimester)
Adult or Peds: Calcium Antacid
If a person has been
given albendazole in
the past six months
(at the clinic or the
school), do not
repeat.
Cimetidine/ranitidine
Ginger is a traditional
treatment
Peds and Adults: Ranitidine
Page 13 of 33
Updated: March 27 2014
Diagnosis
(Suspect PUD, GERD,
gastritis, GI bleed)
Diarrhea (mild to
moderate)
Cholera
Diarrhea
(severe)
Syndrome
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Primary Treatment
duration
GI bleeding
Weight loss
< 1 week duration
< 10 dehydration
Non-toxic
< 5 stools/day
No blood in stool
Rice water diarrhea
Rapid dehydration
Alternative
Treatment
Infants: Continue breastfeeding.
Supplement with ORS. Recheck
the next day.
Peds: ORS and recheck in 2-3 days
Adult: ORS
ORS or IV hydration is essential
> 1 week duration
> 10% dehydration
> 5 stools/day
Blood and mucous in
stools
Febrile
If the cholera
treatment center is
active in Leon or
Jérémie, this may be
a referral source for
severe disease.
Consider
hospitalization if toxic
and continued
hydration needed.
Peds: ORS in clinic. Consider IV
hydration
TMP-SMZ or amoxicillin if
bloody/mucoid stool
Adult: ORS in clinic. Consider IV
hydration.
Cipro or TMP-SMZ if bloody/mucoid
stools.
Consider adding
Metronidazole.
Peds: Amoxicillin for 7-14 days
Adult: TMP-SMZ
Non-pregnant woman needs 3
days, men and pregnant women
need 7 days. (Do not use TMP-SMZ
within 2 weeks of EDC in pregnant
Peds: TMP-SMZ
Recheck next day in
clinic.
GENITOURINARY
SYSTEM
Cystitis
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Dysuria
Frequency/urgency
Incontinence
Positive urine dip stick
for nitrite and LE
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 14 of 33
Adult: Amoxicillin or
Doxycycline
Updated: March 27 2014
Diagnosis
Pyelonephritis
Vaginitis
Assume BV/trich: Trich
extremely common in
Grand’Anse
Syndrome
Primary Treatment
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Fever
Flank or abdominal pain
Dysuria
Frequency/Urgency
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Discharge
No abdominal pain
Not pregnant
+/- itching
Trich is extremely common
in Grand’Anse and men
should be treated for
trichomonas as well.
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Frequency
Urgency
Diminished stream
Prostatitis
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
Older men
+/- non-purulent
discharge
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Peds and Adult: TMPSMZ
Consider ceftriaxone
if toxic or not able to
take oral meds.
Adult: Nystatin or
clotrimazole cream.
Adult
Metronidazole 2 gram po once
Fluconazole 150 mg po once
Male: purulent urethral
discharge, prostatitis
 Female: discharge with
lower abd pain OR
 Female: discharge AND
age 16-31
Benign Prostatic
Hypertrophy
Adult: Cipro or amoxicillin
Peds: Needs exam.
Add candida RX if itching
OR if diabetic
Gonorrhea/Chlamydia
women.)
Peds: ORS and amoxicillin
Alternative
Treatment
For females 16-31 see note under
GC/CT and treat for GC/CT as
well as for BV/Trich
GC: Ceftriaxone 250 mg IM or cipro
500 mg po
Metronidazole 2 gram po once
Azithromycin is
preferred for CT as
one time treatment
(DOT) in clinic
assures compliance
and treats M.
genitalium as well.
Treat partners.
Adults: Terazosin 1-5 mg daily in
single dose at bedtime.
Foley for urinary
retention
Adult: Doxycycline for 14 days or
Bactrim for 14 days
Adult: Erythromycin
for 14 days
Chlamydia: Azithro 1 gram po or
doxy 100mg BID 7 days
Page 15 of 33
Updated: March 27 2014
Diagnosis
Pelvic Inflammatory
Disease
Syndrome


HIV

Syphilis


Primary Treatment
Lower abdominal or
pelvic pain
Tender cervical
movement
High degree of
suspicion.
Anti-TP positive, NonTP positive results
assume active,
untreated tertiary
syphilis and treat
Anti-TP neg, Non-TP
negative no treatment
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Adult: Ceftriaxone IM and
doxycycline and metronidazole for
14 days
Treat partners
All patients being referred for HIV
infection need to be seen by the
local Haitian nurse prior to referral
to Jérémie. The local nurse can
help address the many social and
cultural and also help ensure the
patient gets followed appropriately.
Benzathine PCN 2.4 mil units IM for
three weeks.
-Treat partners

Alternative
Treatment
Adult: Ciprofloxin 1
gram and doxycycline
100 mg BID for 14
days
-All pregnant women
with HIV should be
referred to HHF.
- All non-pregnant
people with HIV
should be referred
to HSA.
Ceftriaxone (but
lacking studies to
prove effectiveness)
Anti-TP positive, Non-TP
negative suggest treated past
syphilis infection or possibly
very early primary syphilis.
Review patient’s history and ask
if they received the penicillin
shots in the past. If they have
been treated in the past, no
treatment is necessary. If there
is doubt about past treatment
OR if recent infection is
suspected, treat.
Page 16 of 33
Updated: March 27 2014
Diagnosis
Syndrome
Primary Treatment
Alternative
Treatment
MUSCULOSKELETAL
SYSTEM
Myalgia or arthralgia


Osteoarthritis


Low Back Pain

Vague, generalized
symptoms
Minimal physical
findings
Painful joints
Joint swelling or
disfigurement
History of injury
Adult and Peds: APAP
(Rural Haitians live a physically
demanding life. Muscle and joint
pains are common.)
Adult and Peds: APAP
Adult and Peds:
Ibuprofen
Adult and Peds: APAP
(Most rural Haitians are subsistence
farmers that spend much time
stooped over tending to their crops
by hand)
Adult and Peds:
Ibuprofen
Generalized or focal
shaking.
Intermittent
Recurring
Adult and Peds: Seizure evaluation
will require referral. Tegretol is the
primary drug available in Haiti
Hysterical reactions
and pseudoseizures
are frequently
misdiagnosed.
Elevated fasting blood
glucose above 126
mg/dl.
Hemoglobin A1c should
be used only for
monitoring

See Diabetes
Management
Guidelines.
Adult and Peds:
Ibuprofen
NEUROLOGICAL
AND ENDOCRINE
SYSTEM
Seizures



Diabetes


2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team

Hemoglobin A1c results should
be interpreted cautiously in
patients with severe anemia.
Diabetes treatment goal is <7%
A1c
Page 17 of 33
Updated: March 27 2014
Diagnosis
Goiter
Syndrome
Primary Treatment
Alternative
Treatment
Nontoxic goiters are
common. Treatment
with iodine does not
shrink goiter.
Prevents increase but
may not be realistic
Symmetrical thyroid
enlargement
 Non-tender
 Not thyrotoxic
 Enlarged
Adults: Oily iodine single dose (400
mg) annually, if available.
Iodized salt
Impetigo

Multiple, crusted skin
lesions
Clean daily and apply Neosporin
ointment.
Adult and Peds: Amoxicillin
Adult and Peds:
Erythromycin,
cephalexin
Scabies


Pruritus
Generalized lesions with
foci on hands, waist,
axilla and groin
Adult and Peds: Ivermectin .2 mg/kg
Treat entire family
Wash linen and place in the sun for
24 hours.
Trim finger nails
Pregnant women and
children less than one
year of age: Benzyl
benzoate
DERMATOLOGY
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 18 of 33
Updated: March 27 2014
Diagnosis
Syndrome
Pediculosis (lice)



Eczema

Primary Treatment
Nits in the hair
Scalp itching
Adult arthropod seen
Tinea capitis
Dry, scaly patches of
skin
 Atopic areas affected
Raised, scaly scalp lesions
Tinea versicolor

Hypopigmented patches
of skin
Tinea corporis (Ringworm)
Tinea cruris (Jock itch)
Tinea pedis (Athlete’s foot)
Pruritus

Raised, scaly annular
lesions with central
clearing
Generalized itching
without rash

2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Adult and Peds: Benzyl Benzoate
for 12 hours.
Treat entire family
Wash linen and place in the sun for
24 hours.
Trim finger nails
Peds and Adults: Hydrocortisone
1%
Griseofulvin 20-25 mg/kg/d for 6-8
weeks.
Fluconazole 3-6 mg/kg/d for 6
weeks
Ketoconazole 400mg once
Alternative
Treatment
Relatively uncommon.
Ivermectin can be
used for severe head
lice
Severe: Prednisone
(oral)
Topical treatment is
ineffective
Fluconazole 400mg once
Topical antifungal cream
Diphenhydramine
Hydrocortisone cream
Page 19 of 33
Hydrating lotion
Updated: March 27 2014
Diagnosis
Syndrome
Primary Treatment
Alternative
Treatment
MISCELLANEOUS
CONDITIONS
Malaria
Anemia





Periodic fevers
Headache
Myalgia
Malaria test
If Hgb <6, test for
malaria.
Peds and Adult: Chloroquine 10
mg/kg then 5 mg/kg six hours, third
dose in 24 hours, and fourth dose
the next day.

Pale conjunctiva and
nail beds
Test frequently
Adult:
Hgb ≤ 7, two Iron/Folate bid for 3
months
Hgb 7-10.5, one Iron/Folate daily for
three months
Hgb ≥10.5 but Ferritin < 20, one
Iron/Folate daily for 3 months.
Peds:
≤ 2 year old: 25 mg essential iron
per day for three months
≥Over 3 year old: 60 mg essential
iron per day for three months

Malaria testing is not needed for
every patient that says they have
malaria.
Cerebral malaria:
Peds: Quinine base 8 mg/kg IV q 8
hours.
Adult: Quinine 600 mg q 8 hours
Elemental Iron Conversions:
Ferrous Fumarate = 33%
Ferrous Sulfate= 20%
Ferrous Gluconate =12%
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 20 of 33
Treat for worms
If Hgb <6, test for
malaria
Hgb <5 g/dl refer to
the hospital for
transfusion
Ferritin is added by
the lab for nonpregnant women 1835 with Hgb ≥10.5 to
detect early iron
deficiency (before
Hgb drops).
Updated: March 27 2014
Diagnosis
Typhoid Fever
Syndrome




Primary Treatment
Fluids
Amoxicillin


High Fever
Diaphoresis
Abdominal Pain
Diarrhea (often nonbloody.
Sore Throat
Weakness and Fatigue
Animal Bite


History of bite
Open or infected wound
Clean and Debride
Peds: Cephalexin
Adult: Doxycycline
Infected Wound



Dirty wound
Purulence
Redness/Induration
Clean and debride.
Tetanus immunoglobulin (250500IU IM) (if available)
Tetanus toxoid (if available)
Adult and Peds: Cephalexin
Malnutrition



Check HIV, Syphilis and Hgb
Check Middle Upper Arm
Circumference (MUAC) for children
6 mo. to 5 years. Refer if <11.5 cm.
Immunizations


Wasting
Growth retardation
Bilateral Pitting Pedal
Edema
Kwashiorkor syndrome
Well Child Care
Family Planning

Health Maintenance
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
This is done by the HHF or the
nurse at the Leon Dispensary.
Ask to see the “National Health
Card” for all children, and reinforce
the use of this card with all mothers.
This is done through local providers
Page 21 of 33
Alternative
Treatment
Cipro or ceftriaxone.
Peds and Adult: Cipro
or ceftriaxone if
severe infection.
Augmentin if
available.
Peds and Adult:
Erythromycin
Augmentin
Make sure children
are plugged into some
system of vaccination.
OCAs and condoms
Updated: March 27 2014
Diagnosis
Syndrome
Primary Treatment

All women in
childbearing years
should receive an
annual dose of two oily
iodine (200 mg
Iodine/capsule) yearly.
Pregnancy

Do “prenatal lab profile”
on all confirmed
pregnant patients who
have not been tested
elsewhere.
Insomnia

History
Refractive Vision Problems


History
R/O Cataracts
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Alternative
Treatment
in Jérémie (such as Gebeau).
are readily available
Remember this is a predominantly
over the counter.
Catholic society, so respect the
Other types of family
health beliefs on family planning.
planning (depo, IUD
HHF is also a Catholic Organization. and implants) are
The mission funds cannot be used
available from local
to support referral for contraception. providers.
Prenatal vitamins and Iron
Refer High Risk
single dose of Oily Iodine (Yodiol).
Pregnancies to HHF
Refer all newly identified pregnant
Centre of Hope (see
clients to the dispensary nurse. She Referral Table for
will ensure the client gets prenatal
specific High Risk
care and monitoring.
Criteria)
Common complaint. Relieving
chronic pain syndromes may help.
Diphenhydramine for severe cases.
Reading glasses may be available
Eye clinic in Gebeau
but we do not provide
referrals
Page 22 of 33
Updated: March 27 2014
MEDICAL REFERRALS
The medical mission is able to provide referral for care we cannot provide in the clinic but resources are constantly
changing. Providers who are considering a referral should consult with another experienced provider.
The Haiti Medical Mission has a funded system of referrals that is supported through the St. Francis of Assisi Catholic
Church.
The reputation of the Haiti Medical mission has grown significantly in the past decade. There are many patients with
increasing complex medical problems coming to Leon. The mission is increasingly challenged by this surge of more
complex patients that need specialty care. We need to manage our referral process so that the number and cost of the
referrals do not bankrupt the mission, and ensure that patients are being referred in a timely manner to the right provider
that is able to offer the services they need.
Every patient referred from the mission will have a consultation sheet and a copy of any diagnostic studies that have been
performed (lab or ultrasound). The referral request will be reviewed by the referral coordinator and, if approved, the
referral coordinator will provide the patient with a referral form. Transportation or payment for transportation is only
provided on a case-by-case basis. Pharmacy costs are only covered on a case-by-case basis for extremely ill patients.
Referral charges are paid at the conclusion of the mission, or the beginning of the next mission by the Referral
Coordinator. If patients return to the dispensary with questions or concerns about prior referral matters (payment, couldn’t
see the doctor, etc.), they need to be referred back to the Referral Coordinator.
Some patients referred on previous missions will return to clinic requesting another referral. Send them back to the
Referral Coordinator for case management and disposition. We cannot refer patients multiple times for the same
problem. For example, some patients with hernias will return to the next mission with the same hernia requesting another
referral. There will be many stories about what happened to the previous referral and money. Some are legitimate, but
others are people who have learned to scam the system. It is the Referral Coordinator’s responsibility to sort out these
issues.
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 23 of 33
Updated: March 27 2014
Commonly Referred Conditions
Many specialty referrals in the US are done for medico-legal reasons or to confirm a primary care diagnosis. Fortunately
in Haiti there is little medico-legal reason to refer, and there are insufficient resources to justify confirming a primary care
diagnosis if the ultimate treatment course will not be changed. Therefore, refer clients when you are unsure of the
diagnosis and there are treatment options for the “definitive” diagnosis that cannot be provided by the medical team. The
mission does not have the resources to provide an assurance to mission providers of the accuracy of their diagnosis if
there is not benefit for the patient.
Referrals to Port au Prince
Referrals to Port au Prince are generally not done. They should first be discussed thoroughly with the team leader and
lead physician and only made after directly contacting the receiving agency to ensure they can take care of the patient
and are willing to receive them.
Conditions not needing referral include:
 Toothaches (unless there is an underlying dental emergency)
 Refractive vision error. Patients can get refraction at Gebeau for a fee. The mission sometimes has fixed diopter
reading glasses for aging eyes only (limited to patients older than 45 years).
 Lipomas or any other non-cancerous disfiguring growths.
 Fibroids (unless there are secondary complications like bleeding and anemia)
 Tubal Ligation and contraception (This is a Catholic dispensary.)
 Cosmetic or elective procedures
 Non-toxic goiter. (These are often very dramatic, but most often not problematic.)
 Physical therapy
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 24 of 33
Updated: March 27 2014
The table below shows the common referral sources and the types of medical conditions that are generally referred to
these sources. When other forms are needed, the referral coordinator will complete as required.
Condition
Anemia (Severe)
Referral Guidelines
Guidelines/Comments
Hgb <5 g/dL (Non-pregnant adults and children)
Hgb <6.5 g/dL (Pregnant Women)
Banked blood is not consistently available and generally
limited to whole blood (no component therapy),
Breast Lumps
Lumps, Masses, Suspected Breast Cancer
Referral Agency
Non-pregnant adults and
children: Hospital San
Antoine
Pregnant Women: Centre of
Hope
HHF Breast Clinic
Complete HHF Breast Clinic Form
**Obtain phone number where patient can be reached.**
Cardiac Surgery
Cataracts
DO NOT send patient. Explain that HHF will contact
when breast team is scheduled for ultrasound and
biopsies.
No resources are available in Haiti.
Check vision with eye chart.
N/A
Gebeau
Vision must be 20/200 or worse to be considered for
referral.
Upper age limit is 80 years if in good health. (Lower age
limit if in poor health.)
Cleft Lip / Cleft
Palate
Club Feet
Dental Care
Complete Gebeau Referral Form
Functional impairment
Functional impairment
Extractions.
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 25 of 33
Operation SMILE through at
Hospital San Antoine
Club Foot Program at
Hospital San Antoine
Local Haitian Dentist (at
Updated: March 27 2014
Restorations such as fillings are not reliably available.
Developmental
Delays
Diabetes
Eye Issues
Resources are scarce. Often better to provide patient
education and have them return to the clinic for follow-up
rather than referral.
ONLY when indicated by Diabetes Management
Guidelines (Page 29)
Glaucoma, pterygium, persistent eye infection
(unresponsive to treatment), cataracts (see above for
cataract guidelines).
clinic one day a week).
No referral form needed.
Instruct patient to come back
and see dentist on scheduled
day.
N/A
HHF
Gebeau
Upper age limit is 80 years if in good health. (Lower age
limit if in poor health.)
No referrals for eyeglasses or refraction.
GYN Surgery
Hernias
Complete Gebeau Referral Form
No referrals for tubal ligation or termination of pregnancy.
Other GYN surgery is available.
Umbilical Hernias: Do not refer
Hospital San Antoine
Hospital San Antoine
Inguinal Hernia:
a. Smaller than a grapefruit, easily reducible, not
interfering with work—Do not refer
b. Smaller than a grapefruit, not easily reducible, not
interfering with work—Do not refer
c. Larger than a grapefruit, interfering with work or
activities or daily living—refer.
NOTE: Upper age limit is 80 years if in good health.
(Lower age limit if in poor health.)
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 26 of 33
Updated: March 27 2014
HIV Infection
Malnutrition
(Pediatric)
Orthopedics
Physical Therapy
Prostate Surgery
Pregnancy (Low
Risk)
Pregnancy (High
Risk)
Always involve the local nurse when informing the
patient of HIV positive status. She will provide
additional counseling to the patient.
Bilateral pitting pedal edema OR Middle Upper Arm
Circumference (MUAC) of <11.5 cm (Children 6 mo.
to 5 years)
Check MUAC measurement and document in chart
and on referral form.
Send to HSA.
NOTE: If the patient only needs an X-Ray and
could be managed in clinic, patient can be sent to
Gebeau for X-Ray and they will send film back with
patient.
Not Readily or Reliably Available. Educate patient
and family about what they can do on their own.
Prostate surgery not readily or reliably available.
DO NOT refer. Introduce patient to local clinic nurse
for integration into local care system.
High Risk Criteria:
a. Hgb <6.5 g/dL
b. Hgb 6.5-8.0 g/dL (at 8 mo.)
c. Hypertension (>140/80)
d. Maternal cardiac problems
e. Severe asthma
f. Diabetic
g. Persistent vaginal bleeding
h. HIV Infection
i. Active TB Infection
j. Twins or Multiple Fetuses (at 8 mo.)
k. Age <17 (first pregnancy, at 8 mo.)
l. Age >40 (at 8 mo.)
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 27 of 33
Adults, children: Hospital San
Antoine
Pregnant women: HHF Centre of
Hope
Hospital San Antoine (HSA)
Missionaries of Charity
Hospital San Antoine
N/A
N/A
N/A
HHF Centre of Hope (Complete
HHF Referral Form)
NOTE: If there is a maternal
emergency, notify the local nurse
or clinic staff. They can contact
the Centre of Hope ambulance to
bring the mother to the Centre of
Hope or Hospital San Antoine
Updated: March 27 2014
Seizure Disorder
(New Diagnosis)
Trauma/Other
Emergency
Tumors,
Undiagnosed
Cancers
m. Breech presentation (after 8 mo.)
n. Prior C-Section
Only for a new diagnosis
Consult with team leader and experienced providers
before referring. It may be better to manage patient
in the clinic. Services at Hospital San Antoine are
unreliable and often unavailable especially at night
and on weekends when there may be no doctors.
Patients not seen for >12 hours.
Imaging at HSA is limited to X-Rays. Biopsies
(pathology) are typically not performed.
See above section on Breast Lumps for Breast
Cancer.
HHF performs PAP smears
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 28 of 33
HHF
Hospital San Antoine
Hospital San Antoine
HHF: Pap smears for cervical
cancer
Updated: March 27 2014
CHRONIC DISEASE MANAGEMENT AND REFERRALS FOR PERSONS OUTSIDE LEON AREA
The provision of chronic disease medication and paid referral care has attracted persons from far outside the Leon region.
While these people also have great need, their growing numbers are taxing the limited resources. The mission must
restrict ongoing referral and medication services to those outside the Leon region. If people present for services and are
identified by the local clinic staff to be from outside the Leon region, they will be provided services for that visit (including
medications if indicated) but the clinic cannot provide for ongoing care or referral. They will be told that they must find
alternative medical care closer to their homes.
HOSPITALIZATION
Hospital San Antoine, Jérémie: Located about 45 minutes by vehicle in Jérémie. It is NOT like the hospitals in the US
and Canada. Services are intermittent, unreliable and often not available. It has electricity intermittently. It can sometimes
do surgery. It is staffed by local Haitian private physicians, and Cuban physicians who do “national service” in Haiti. The
Cuban physicians are very well trained and often have sub-specialization. Limitations on equipment and supplies often
make it difficult for them to practice their specialties.
Patients and their families must provide their own meals and purchase all the supplies and medications that they need. It
is “pay as you go”. Supplies are purchased as they are needed. If there isn’t money, there isn’t care. Patients must have
a family member accompany them to do bedside care and to cook meals. Without a family member, patients will not fare
well in the hospital.
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 29 of 33
Updated: March 27 2014
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Page 30 of 33
Updated: March 27 2014
Ensure that all relevant lab results are also recorded on
the dossier in the event that the lab slip gets separated
from the medical record.
SAMPLE FORMS
Place the provider’s name or “Triage”
if ordered from the triage desk.
Put all relevant information about the
patient’s condition that you will need
for follow –up. Assume you will NOT
have the patient’s full medical record at
the time of the follow-up.
Place the day you want the patient to return.
For the current mission only. Do not give
these to return to subsequent missions.
Return to Clinic Form
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Laboratory Sheet
Page 31 of 33
Updated: March 27 2014
Ensure that you have the right patient. Check the name
with the patient, and make sure the age is appropriate to
the patient.
Dates in Haiti are in the format DD/MM/YY
Triage note.
Note referrals and follow-up
recommendations.
Subjective and objective
findings should be brief, but
adequate to support diagnosis
and treatment.
Adult Dossier (progress notes)
Adult Dossier (Face Page)
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Medication doses for
routine OTC drugs are
not needed. (ibuprofen,
acetaminophen, etc.)
Page 32 of 33
Updated: March 27 2014
Pediatric Dossier (growth chart)
Pediatric Dossier (progress note)
More reliable (used) growth charts are in the child’s “National
Health Card”. Ask all parents about this card, and encourage
them to bring it to the clinic on ALL visits.
2014 Haiti Medical Guidelines
© 2014 Seattle-King County Disaster Team
Check vaccination status of all children at all visit. Encourage
parents to take children for vaccinations.
Page 33 of 33
Updated: March 27 2014