Ascend Travel Medical Mission Leadership by Ascend Travel

Medical Mission Leadership Manual

Solutions for Ending Poverty and Creating a Brighter Future

Medical Expedition Training Manual Section 1: Introduction, Purpose and Approach Overview The Medical Team Activities and Approach How to Use This Manual and What It Contains Section 2: Field Guide for Humanitarian Health Professionals Purpose Background Basic Principles Primer on 3rd World Disease Section 3: Protocol for Rural Health Clinics & Community Health Worker Training Clinic and Training Overview / Set-Up Patient Screening/Check-In/Flow/Teaching Stations/Kits Medical Room / Dispensary Health Worker Training Section 4: Establishing Expeditions with Surgeons and other Professionals Medical / Surgical Team Organization Important Tasks Setting Up a Surgical Team Packing List: Medications and Supplies Important Consideration when Working with Hospitals Examples of Successful Clinic Projects in Peru and Bolivia Medical Surgical Team Positions Other Health Care Resources Available Appendix - Health Clinic Resources Antibiotic / Disease Cross-Reference Logistics - Set-Up of All Health Tents Inside Layout of Medical Tent Health Teaching Tent Layout Field Medical Clinic Treatment & Tracking Tool (Urgent Pink Card) Field Medical Clinic Treatment & Tracking Tool (Non- Urgent White Card) Dosing Instruction Diagrams

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Section I. Introduction and Purpose As a medical team working in a developing country, Ascend has a program for both Urban / Suburban Medical Follow-up, including surgeries and professional exchange, and we have a program for Rural Health Campaigns, including teaching stations, field medical, dental and/or eye screening clinics. Some medical expeditions will include both urban and rural components. Comprehensive expeditions generally focus on the Rural Health Campaign. Third world countries are faced with difficulties in obtaining effective medical treatment for infectious diseases. Ascend's goal is to educate and provide projects to raise awareness faced by children and families in the villages it serves. Ascend is an organization based on volunteerism. In helping to teach and relieve the suffering of others, each volunteer gives freely of his or her humanity and creates a limit between self and community to those in need. Ascend has set up guidelines for the medical team, to ensure the same standards on each expedition. The medical team's goal on each expedition is to teach and treat as many people as possible in a short period of time with the utmost concern and care. Each medical team also wants to offer hope, dignity, and a place from which villagers can start to restore good health to their village.

The Medical Team Activities and Approach Prior to the expedition the medical team is involved in: Ordering and procuring medical equipment and medical and hygiene supplies that are going to be taken to the host country (see lists in Section IV of the manual). Packing or arranging for the packing of medical equipment and supplies. Planning the medical protocol that will be used while in the host country. Working with in-country facilitators to identify the following: 1) names of health workers with village location, 2) past training if any, 3) materials in their possession i.e. Where There is No Doctor, Good Health Begins at Home, 4) whether or not they have an Ascend Health Worker ID card, 5) requested areas for additional training. During the expedition the Rural Health Campaign may include: Teaching self-help health practices to villagers, including teaching stations addressing respiratory illness, STDs, gastrointestinal problems, skin problems, hygiene, nutrition, maternal & newborn care. Teaching paramedical techniques, including first aid Teaching community healthcare workers Dental hygiene, diagnosis & treatments, including extractions and fillings

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Eye-screening clinic, including fitting with glasses and/or eye ointments Medical diagnosis & treatments for internal and external medical problems Medical Team Activities Each team project consists of approximately four to five health care providers and four to five Ascend expedition participants. Each participant works side-by-side with medical personnel to help with treatment. On the first day in the clinic the medical personnel presents an orientation to the participants as to where the medications and supplies are located. This allows the participants to become familiar with each medication and its use and helps with the flow of patients. It is the goal on every expedition that every participant who wishes to work in the medical clinic be given the opportunity to do so. At times there will be participants that want to work solely in the medical clinic. Every effort is be made to accommodate this wish. In order to allow opportunities for everyone who wishes to participate in the medical operations, and not over load the operation, shifts are set up. Each shift is usually four to five hours long. The outgoing participant trains the incoming participant. The incoming participant observes and learns until he or she is comfortable with the flow and then moves in to work side-by-side with the medical personnel. It is Ascendâ&#x20AC;&#x2122;s goal to have a local doctor from the surrounding area participate in The Team Project. They are familiar with the local health problems and diseases in the local area and help educate those on the project. This allows Ascend to improve its delivery of health care. The local doctor can also be a good resource for any follow up work that needs to be done after the expedition is over. Ascendâ&#x20AC;&#x2122;s InCountry Director can establish the criteria for selection of a local doctor. Patient Care Most of the villages that are treated suffer from similar diseases. Diseases most frequently often encountered are: malaria, relapsing fever, amoeba, STD, URI, UTI, elephantiasis, worms, scabies, malnutrition, and wounds/skin. Every effort is made by the medical team to identify these diseases and treat them. All of these diseases have been addressed and their treatments are documented in the Field Guide for Health Professionals Practicing in the Third World. Women and children are often the most vulnerable. Each mother that comes to the clinic, whether seen by a doctor, nurse or village health care worker, receives training on maternal/newborn care and nutrition, how to treat diarrhea, how to recognize signs of severe illnesses and hygiene. Each expedition will have on hand special milk and food products for the severely malnourished or ill. Patient Screening Every adult wanting to be seen by the Ascend medical team is screened prior to entering the medical facility. The process of screening patients is difficult and requires at least one stateside doctor or nurse and an in-country nurse. Prior to each expedition Ascend determines the size of the village, however neighboring villages travel to the clinic. It is not uncommon to have eight or nine villages represented at the clinic. Ascend In-Country Facilitators work with the villagers ahead of time and ask each village chief to bring those with the most immediate need first. Medical teams should strive to treat these

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people first. The villagers are aware of those in need of immediate medical attention and assist the Ascend medical team in this selection process. Each day the medical team “scans” the crowd for those that appear to be most seriously ill. This is done with both in-country medical personnel and medical personnel on the expedition team. Because of the large number of waiting villagers, areas are cordoned off with ropes and other means to assist in “traffic control.” A villager that has been preselected by the village chief remains at the rope line to assist with the screening of patients. The Protocol for Rural Health Clinics and Community Health Worker Training (Section 3) contains the details of the rural Health Campaigns.

After the Expedition and Return to U.S. the Medical Team is involved in: Compiling a report of activities done in the host country and delivering that report to Ascend Collecting photos from all the medical team and delivering them to Ascend

How to Use This Manual and What It Contains Team Leaders should acquire and use a copy of this manual, especially following the guidelines and checklists suggested. Copies should also be provided to the members of the health/medical team once they have been identified. This manual includes things to consider while preparing for the expedition and things to consider and prepare for during and after an expedition. It contains useful hints gleaned from past expeditions on how to enhance participants' success during the entire period. It covers items and issues that might be important for the Team Leader to consider while carrying out the assigned activities. And finally it contains resources that are available to assist the team in carrying out a successful expedition. The appendix contains the following resources for health clinics: 1. 2. 3. 4. 5. 6.

Antibiotic/Disease Cross-Reference Logistics and set-up diagram Diagram inside the clinic tent or building Diagram of teaching stations Clinic registration card samples Dosing instruction sheet

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Section 2. Field Guide For Humanitarian Health Professionals Purpose: The purpose of creating a field guide is to assist healthcare providers, who come to a humanitarian expedition with divergent levels and kinds of expertise with diagnosing and treating illnesses in a field clinic setting. These guidelines will have to be adapted to different regions of the world and to resources available in a particular area. However, the common goals of 1) identifying diseases that many providers have never seen, 2) providing basic health care with low cost medications and supplies that are locally available, and 3) offering health education for the prevention and maintenance of health, for as many individuals as possible in a short time frame, make a simple field guide an essential tool. Background: The overwhelming needs evident in the developing world make knowing where to focus attention and resources difficult. Large families of multiple generations, arrive at the clinic, often having come from great distances to be seen. They want treatment for all of their complaints ranging from acute illness to congenital malformations, to problems that afflict virtually everyone and are likely caused by daily living conditions or prolonged ill health and poor nutrition. With limited time and resources, it is essential to establish priorities and establish a consistent approach to dealing with the individuals and their illnesses. Studies done by UNICEF and the WHO demonstrate that the greatest needs at the family level are the health and survival of the children. "The combination of malnutrition and infection is the leading cause of death among young children in developing countries. Malnutrition alone is estimated to account for more than half of deaths annually. Other leading causes of death are malaria, acute respiratory infections, diarrheal diseases, TB, and HIV/AIDS, all frequently complicated by varying degrees of malnutrition." (Pediatric Annals 10/04) Those who survive often face lifelong problems due to the impact of malnutrition on all aspects of health, growth, and physical, emotional and social development of a child. Adults face acute and chronic health problems that interfere with family functioning, maintaining a livelihood, and therefore the health and wellbeing of their children. Some of their problems, such as TB, are beyond the scope of care in a field clinic, but parents often suffer from the same complaints as children and simple treatments that can keep a family functioning will positively impact the health of children. Preventive education, teaching self-care for daily aches and pains, and encouraging the use of community resources for diseases such as TB are also a vital part of health intervention on humanitarian expeditions. Another issue that arises for the medical professional is trying to practice responsible, cost-effective medicine without diagnostic tools and tests available. Diseases share characteristics and often problems coexist, making precise diagnosis virtually impossible. Language and translation barriers, as

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well as limited literacy skills of the clients further compound the problem of choosing appropriate and realistic treatments. However, this manual will provide guidelines for how to provide health care for these populations most effectively and efficiently. Basic principles: 1. Keep it simple. 2. Giving more than 1 or 2 medications and instructions to each family member is too complicated. It would be better to treat 1 problem fully than several poorly. 3. Choose the most pressing and potentially life-threatening or life-changing problem to treat. 4. Look for ways to treat more than one problem with a single medication. 5. Remember that exposure to antibiotics has been limited in underdeveloped countries, so narrow spectrum antibiotics in low dosages for a short duration is usually sufficient 6. Pictures can be as or more effective than written words, as illiteracy is common. 7. Treat as many complaints as possible with simple, readily available home measures. 8. Adequate nutrition, good personal hygiene, and clean water underlie virtually all of the health problems you will see, so prevention should be included in all instructions for treatment of an illness. 9. Use the experience of health care workers and translators to learn about how common illnesses present in that area.

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Primer On 3rd World Disease Common complaints/illnesses: 1. Malnutrition (all regions) a. "Dry" or marasmus (not getting enough of any kind of food) i. small, thin, wasted body, potbelly ii. thinning hair Treat with any foods, especially energy foods. b. "Wet" or kwashiorkor (lack of protein & intake of poorly stored food) i. feet, hands & face swollen ii. color loss in hair & skin Treat with fresh and protein-rich foods. 2. Malaria (Africa, Tropical/Subtropical regions) a. mosquito-borne; occurs below 2000 m. b. 3 stages in attacks i. shaking chills for 15 min. to I hr., headaches & weakness ii. fever lasting several hours to days iii. sweats following fever b. recurring attacks every 2-3 days feeling more or less well between times c. accompanied by myalgias, headaches d. children may be listless e. splenomegaly - spleen may be huge after having malaria several f. may be confused with relapsing fever; unless malaria can be confirmed, treat with single dose Doxy* Treat with chloroquine*; where there is chloroquine resistance, treat with Fansidar*; consider adding single dose TCN*, PCN* for relapsing fever 3. Gastrointestinal problems (all regions) a. Intestinal worms- all treated the same i. Numerous worms-roundworm, pinworm (aka threadworms), hookworm, tapeworm, whipworm ii. Whipworm may cause rectal prolapse; reduce by pouring cold water on it iii. Roundworms cause swollen bellies, may crawl out mouth iv. Roundworms, tapeworms, pinworms can be seen in stool v. Hookworms & whipworms may not be seen in stool vi. Tapeworm comes from beef or other meat not well cooked Treat all with Mebendazole* b. Diarrheal diseases i. Shigella (or other bacterial) - diarrhea + blood + fever Treat with Cipro* or Cotrimox*, ORS & fever control ii. Amoeba - diarrhea + blood - fever (may look like IBS with alternating diarrhea, constipation, mucous, frequent stools) 6

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Treat with Tinidazole* & ORS iii. Giardia - bloating, frothy stools, smelly, sulfur tasting burps, no fever or blood Treat with Tinidazole* iv. Cholera - rice water stools, causes severe dehydration Treat with aggressive ORS rehydration & Cipro*, Cotrimox* or Doxy* c. Typhoid i. An infection of the gut that affects the whole body-lasts 3 weeks & will resolve if no complications ii. Begins with headache, sore throat, dry cough iii. Fevers-up & down but progressively higher over time iv. Pulse relatively slow for degree of fever v. Sometimes vomiting, diarrhea, or constipation vi. Faint spotty rash may appear vii. Weakness, weight loss, dehydration Treat with or Doxycycline* or Cipro* for at least 2 weeks; fever control; ORS d. Heartburn-probably due to lack of food, high coffee intake Treat with small, frequent meals, no coffee & raise head and chest if possible 4. Genitourinary (all regions) a. STD (Gonorrhea, Chlamydia) i. Men 1. painful urination + /- discharge; history of >1 sexual partner ii. Women 1. pain &/or bleeding after sex 2. pelvic pain 3. fever Treat with "STD pack" (Cipro 500 mg. x 1 and Doxy 100mg. bid x 7 days); treat all partners b. Cystitis (women) i. painful urination with frequency ii. blood in urine, Treat with Cotrimox*, Cephalexin* or Cipro* c. Kidney infection i. Flank pain & tenderness to percussion ii. + /- painful urination ii. blood in urine iii. nausea iv. fever v. can be difficult to distinguish from musculoskeletal back pain & od1er back pains with fever-malaria, relapsing fever Treat with Cipro*, Cotrimox* or Cephalexin* d. Vaginitis i. Itching /burning suggest yeast

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ii. Fishy odor &/or increased discharge suggest bacterial infection iii. Difficult to diagnose without microscope Treat with Miconazole* or Metronidazole* e. Postpartum endometritis i. Fever, malaise ii. Pelvic pain iii. Uterine tenderness with exam iv. Malodorous lochia Treat with Cephalexin* and Ampicillin (high doses)* 5. Respiratory & ENT Problems (all regions) a. Otitis media i. Most common in children ii. Fever ii. URI symptoms iii. Treat with Amox* or Cotrimox* b. Otitis externa i. Look for flies or oilier foreign bodies ii. Cerumen inpaction occurs frequently Treat with antibacterial ear drops* and gentle irrigation if large amount of purulent debris or cerumen c. Conjunctivitis i. "pink eye"-infection 1. conjunctival redness, pus, discharge, or matting of eyelashes 2. burning, pain 3. itching or discomfort without redness not likely infected Treat with gentle cleaning with boiled &cool water & clean cloth; TCN or other antibiotic ointment inside eyelids 3-4 x per day if infection suspected ii. Trachoma - is a chronic form of infection 1. spread by flies & touch 2. major cause of blindness 3. begins with red, watery eyes & slowly gets worse 4. after > 1 month, small, pinkish-gray lumps (follicles) form inside upper lids, sclera looks inflamed, & top edge of cornea looks grayish Treat with TCN eye ointment 3-4 x per day x 1 month; most effective treatment is to take TCN* or Doxycycline* x 2-4 weeks iii. Neonatal conjuctivitis 1. occurs in the first 2 days of life 2. eyes red, swollen, with pus 3. will cause blindness if not treated promptly

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Treat with gentle cleansing, TCN ointment qh for 1st day, then tid x 2 weeks; give simultaneous oral Cotrimox*; prevent by cleaning newborns eyes immediately after birth, preferably before they open the 1st time followed by TCN ointment iv. Allergic/irritant conjunctivitis 1. discomfort, esp. chronic, without conjunctival redness & discharge Treat with flushing, gentle wiping d. Pneumonia i. Fever, productive cough with purulent (yellow, green +/- blood) sputum ii. Shallow, rapid breathing; person looks ill Treat with Cotrimox*, Amox *, or Cipro*; see home treatment e. TB i. Prolonged cough, night sweats, weight loss, fatigue ii. Can affect parts of body other than lung Lymph nodes, skin, abdomen) Seek treatment at local clinic; long-term treatment required f.

Dental infection i. Tooth abscess or infection of gums Treat with heat, pain relief measures; if severe or recurrent, treat with Amox*, Cotrimox* or Cephalexin*

6. Skin problems (all regions) a. Scabies i. Common in children ii. Small, itchy bumps feet, lower legs, hands, forearms, genitals iii. Very contagious iv. Can become secondarily infected v. Can be confused with congenital syphilis in infants Treat with benzyl benzoate lotion * and Tetmosol soap; wash all bedding & clothing & hang to dry in sun b. Lice i. Occurs on head & body ii. Very contagious iii. Transmits relapsing fever & typhus (different from typhoid) Treat with benzyl benzoate lotion* and Tetmosol soap; to remove nits (eggs), soak hair with hot vinegar water for 1/2 hr., then comb with fine tooth comb; if vinegar not available, use comb alone; wash bedding & clothing & hang to dry in sun c. Infection i. Impetigo 1. honey colored crusting on open sores or wounds 2. topical antibiotic adequate if lesions small; if more extensive

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Treat With Amox*, Cotrimox*, Or Cephalexin* ii. Cellulitis 1. redness 2. warmth 3. swelling & induration Treat With Amox*, Cotrimox*, Or Cephalexin* d. Fungal infection i. Red, scaly ii. May occur in single or multiple patches or in larger patches iii. Very itchy iv. Look for clearing in the center of lesion v. Can be confused with eczema or irritant dermatitis vi. Causes cracking & peeling of feet with foul odor Treat with topical antifungal 2-3 times/day until healed e. Eczema/dermatitis i. Dry, red, irritated patches ii. Variably itchy iii. Occurs in skin folds, flexures Treat with topical antifungal2-3 times/ day until healed f.

Filariasis/Elephantiasis i. Attacks of painful swelling of one or both feet ii. Cause by worms penetrating soles of feet iii. Swelling progresses up legs into groin & scrotum iv. Elephantiasis is a late sign & does not respond to treatment v. Refer to clinic or hospital with early signs vi. Foot care, ace wraps and elevation for comfort

* See treatment/tracking tool & antibiotic/disease cross-reference (Appendix) for adult & pediatric dosing, contraindications & cautions.

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Section 3. Protocol For Rural Health Clinics & Community Health Worker Training A People-centered and Community足 Strengthening Approach to PROVIDING Health Care DURING EXPEDITIONS and beyond

Components 1. Clinic and Training Overview / Set-Up 2. Patient Screening and Check-In / Patient Flow / Teaching Stations/ Kits 3. Medical Room / Dispensary 4. Health Worker Training

1. Clinic And Training Overview / Set-Up The expedition health team's most important job is to teach- to encourage sharing of knowledge, skills, experiences, and ideas. While temporary treatments, and even follow up on vital medical needs I surgeries can be helpful and even life-saving, our activities as "hands-on" educators with health workers and community members can have more far-reaching, long-term impact than our curative activities. Keeping this in mind, the clinic set up for expeditions should have a focus on teaching, training and empowering health workers and mothers. Even as diagnosis and treatment of patients is undertaken, health workers should have this hands-on experience at the side of expedition medical professionals, so that they benefit from this hands-on training, being encouraged and empowered to be effective in their own communities. The world health organization has documented that over 70 percent of the causes of death in villages could be prevented by health workers with just 7 weeks of appropriate training and support

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A. The Week at a Glance Day 1: Arrive, set up Day 2: Training of health workers. Clinic begins in the afternoon. Day 3, 4, 5: Clinic/ teaching rotations all day. Hands-on training of health workers takes place in the clinic and teaching areas, along with classroom training going on simultaneously. Health workers rotate through the various stations and through additional training. Day 6: Pack up, depart

B. Physical Set-Up Supplies 2 large tents (waiting tents) - one tent to be utilized for patients waiting to see medical personnel and one tent for patients waiting for the teaching tent. Teaching stations 1, 2, and 3 begin in the two waiting tents with oral re-hydration, respiratory illness and STD's. 4 long tables (2 tables per tent) for supplies/dispensing ORS and cough recipe 2 small tables/desks for patient registration (one for each waiting tent) 2 chairs for each registration table 4 tarps/blankets or benches (two for each tent) for patients to sit on Empty Water Bottles for ORS Sugar and salt (to be bought in country)- for ORS recipe 1 large tent (medical tent) - treatment and dispensary 6 long tables for medication & supplies/ dispensing 1 mattress for examinations 4-6 desks/small tables (depending on medical personnel) one for each person 6 chairs for health workers & translators 16 chairs/benches for patients 2-3 benches outside medical tent for patients to sit Medications and supplies for medical tent (see medication and supply lists) 1 large tent (teaching tent) - (4 teaching stations; skin care, hygiene, maternal/newborn and vitamins) 4 tables for teaching stations 4 benches or tarps for patients to sit during teaching 8 chairs for health workers & translators

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Approximately 2000 feet of rope to section off areas outside the waiting tents, medical tent and teaching tent 12 translators- 2 at registration outside the waiting tents, 2 at medical screening, 4-6 in the medical tent, 1 for health worker training. (Plus 4 other translators for other non-medical project activities) 3 guards - to help with crowd control Medical Room / Dispensary This should be a building, large classroom, or large army-style tent in which medical professionals can treat patients and dispense medications preferably placed 50 to 100 feet from waiting area/tent. It should be large enough to accommodate multiple treatment stations (hopefully 4, based on the number of medical professionals participating) and a dispensary area. The medical supplies and medications should be set up inside the tent on the tables allowing for the majority of space in the center for working stations. Ideally, a health worker and translator should work sideby-side with a medical professional at each station with rotation of health workers through various treatment / dispensing, check-in, teaching and triage stations over the course of the clinic. Entrance / exit areas should be roped off, with appropriate roped walkway access from the teaching / triage area and waiting area. It is common to have several people in each family coming to be treated.

Waiting Area / Teaching Stations The waiting area or tent should be placed approximately 50 to 100 feet away from the medical tent. This should be a roped-off area, preferably with shade / rain protection. A large rectangular area with pitched tarp can work well. Benches (if available) should be placed inside the tent for the sickest patients. There should only be one way in and one way out of the medical and waiting areas. Each village will have its own demographics and each medical area will be unique. Two desks or small tables with chairs should be placed at each of the two teaching stations.

2. Patient Screening / Check-In/ Flow / Teaching Stations / Kits Screening And Check-In The process of patient screening can be facilitated nicely if before the expedition arrives, a total number of patients desired (feasible based on the health team going and personnel available in country) is determined for both white cards - non urgent, and for pink cards which are urgent care patients. Community Workers and Community Councils then work together during the two weeks prior to the health campaign to distribute cards fairly. Please note that community members should come as a complete family, and be given a family card, not an individual card. Some

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families will only need teaching, hygiene supplies, triage, etc., and time generally does not permit all families to "see the doctor or nurses." So advance screening is very important, again, preferably with cards being issued in advance. Previously trained community health workers in coordination with their community councils should take on this responsibility. Latin American clinics are generally smaller and thus screening can be done in a more relaxed way. Then to catch those who may have become ill and didn't get a pink card, the expedition should plan to have a medically trained person to screen these exceptional cases as they may arise. Included in this manual are examples of the appropriate screening and registration clinic cards: pink card for those who need to be seen in the medical tent or building, and white card for those who can be treated with basic health and hygiene personnel. For those screening: Before writing anything on a white or pink card, identify the mother, father or guardian/s, then ask them if anyone in the family is very sick. If yes, ask them to identify the person and explain the problem/s. Based on this description and a visual check of the patient by the health worker, a determination is made whether they need to see the doctor (pink card) or if basic treatment and teaching (pain reliever, antacid, simple wound care, worm treatment, lice treatment, basic eye ointment, hygiene supplies, newborn care) is adequate (white card). The card (white or pink as determined appropriate) should then be filled out by the registration team (health workers and/or community council members) with the appropriate family information and given to the family as their "ticket'' to participate in the clinic. On the day of the clinic, families then bring this card to check in and begin going through the teaching stations, and colored cards are brought to the doctor as flow dictates. All patients are to complete the teaching stations whether they see the doctor or not. (So if they are brought to see the doctor before they complete the teaching stations, then they go back and finish the teaching stations after they see the doctor). Each teaching station number is checked on the card once the station is completed, so you can always tell where a patient has or has not been. This way they can complete their card out of order if necessary to accommodate clinic flow. Please make certain children are accompanied by parent or guardian and donâ&#x20AC;&#x2122;t come alone. The intent is to treat the family together whenever possible. Coming as a family unit also facilitates teaching and dispensing. One card should be given per family, not per person. Two or three expedition participants and/ or health workers can manage the flow of the teaching stations and clinic by helping move families with filled out cards (white and colored) through the teaching stations, and escorting the colored cards to the medical tent regularly, to maintain steady flow. At each of the registration desks (one for colored cards, one for white cards) is a health worker / translator who reconfirms that the card is filled out properly in English and distributes the family health guide (in Spanish or Quechua).

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Teaching Stations Whenever possible, the health workers should be doing the teaching at each teaching station. This is an important part of capacity building! Health team members from the expedition should be available to assist as needed (particularly at first to get them started). There are generally seven total teaching stations: three set up to teach the patients as they are waiting in the waiting tent, (oral reÂ hydration, STD's, and respiratory), and four stations are set up in the teaching tent: skin care, hygiene, scabies and worming). Hygiene kits, vitamins and newborn kits can be distributed to those that participate in the trainings. Each teaching station should employ Pro-Literacy Worldwide Methods as much as possible-using visual aids, photos or drawings to encourage discussion, as well as hands on participation, and emphasis on "action item takeaways" based on the group's discussion / demonstration. Be sure to check the number on the registration card once the family completes the station. Also check the appropriate box when they receive a hygiene kit, vitamins or newborn kit. Due to limited supplies, only nursing or pregnant mothers receive prenatal vitamins, unless the doctor prescribes them. Only moms with newborns (children under a year old) receive a newborn kit. Only moms with children under age 5 receive childrenâ&#x20AC;&#x2122;s vitamins. Benches, desks, chairs or mats are nice for the teaching stations when possible. Otherwise, the women and men can sit on the ground or stand Recommended Topics For Teaching Stations - (can be revised according to need). Please note that any stations where supplies are handed out should be in an enclosed, controlled area, rather than out at an "open air" teaching station. Thus the first two stations here can be "open air", where stations 3-will be "enclosed" inside a tent or building: 1. Respiratory Illness and Diarrhea (Cold Care & Oral Rehydration). a. Show visual depicting respiratory illness. Ask them what they see. b. Discuss Symptoms. c. Have their family / friends had these symptoms? d. Discuss causes, discuss prevention, have a mother mix the homemade cough syrup. Also make nasal saline solution and demonstrate vapor tent. Hand out cards showing how to mix cough syrup, prepare nasal saline solution and the vapor tent. (One per family). e. Review action items. 2. STDs (and introduction of Sewing Kit if time permits). a. Show visual depicting spread of venereal disease. Ask them what they see. b. Discuss symptoms. c. Have any of their family / friends had these symptoms? d. Discuss causes-sex with unknown partners, not using protection. Discuss remedies, abstinence, and protection. e. Review action items. f. If time permits, introduce the sewing kit, which they will be given in their hygiene kits at the next station and show them how to use it. Have one of the women demonstrate by repairing an article of clothing or sewing on a button.

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3. Hygiene. a. Ask them what they see. b. Discuss ways to keep themselves, home and family clean, drinking clean filtered or boiled water, using soap whenever possible. c. Have any of their family/friends had hygiene problems or difficulty keeping clean d. Introduce the Hygiene kit. Discuss/ demonstrate the hygiene kit, teach them to use it, and distribute the hygiene kit to each family. Dental hygiene - teach to brush teeth with toothpaste, use dental floss or thread, talk about salt water rinse and bark brushes as alternatives. e. Review action items. NOTE: At this station every person over the age of one and women that are NOT pregnant will receive worm medication if needed. Children's liquid or chewable and adult tablets are available to each patient. Bars of soap are also distributed at this station. One bar of soap to each family to be put inside the hygiene kit, in less the family is large and then two bars are given. 4. Skin Care. a. Show visual depicting skin problems, ask them what they see. b. Discuss symptoms of scabies & lice, Ask about the most common problems / symptoms. c. Have any of their family / friends had a wound, or scabies problems? d. Discuss /demonstrate remedies, hot and cold compresses depending on the problem, and reinforce the importance of personal hygiene. Introduce hygiene kit, teach them to use it, and distribute, demonstrate care of wounds & bites. Teach proper application of scabies lotion. Teach the importance of keeping the lotion out of children's eyes and mouth. Teach the need to wash all clothing and bedding in the home and hang out in the sun to dry. Teach that scabies will re-infest if skin is not kept clean. e. Review action items. NOTE: The scabies medication is poisonous and needs to be kept out of the reach of children and applied only by a trained adult 5. Gastrointestinal. a. Discuss gastrointestinal problems, including diarrhea and vomiting, worms and intestinal Parasites. b. Show visual depicting intestinal pain, Ask them what they see. c. Discuss symptoms. d. Have any of their family / friends had these symptoms? e. Discuss causes-lack of cleanliness, feces to mouth by hands & fingernails, bacteria in water (Look at bacteria through microscope if possible). Discuss remedies: importance of boiling and/or filtering water, washing hands, fully cooking food, importance of latrines and covering them to keep healthy. Discuss that the technology workers in the area can help them build a latrine. Discuss medicines - oral re-hydration (which they have already learned to mix at station.

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1-Liter empty water bottles can be given to mothers (if available) and if they do not have one. Discuss ground Papaya seeds when medicine is not available. g. Review action item.

6. Nutrition, Maternal and Newborn Care (for mothers, pregnant women and infants 0-12 months). Basics of Nutrition and food groups, available foods rich in vitamins, etc. Pre-natal vitamins, adult vitamins, infant liquid and children's chewable vitamins are available, Pre-natal vitamins are given to pregnant women only. Infant liquid drops are given to infants 6 to 2 years of age. Children's chewable vitamins are intended for children 2 and up. Regular adult multivitamins are intended for 13 to adult. Usually vitamins are packaged in 30 tablets. This is a two-month supply, as we instruct to take on vitamins every other day. This will help extend the vitamin therapy. Under the table, bags vitamins, and newborn kits can also be stored. Entrance / Exit areas should be roped off, with appropriate roped walkway access from the teaching area and waiting area a. Show visual depicting malnourished child. Ask them what they see. b. Do they have problems in their own families with malnutrition and proper care for their infants? c. Discuss nutrition, breast-feeding, keeping babies clean and free from flies. d. Introduce vitamins & distribute, introduce newborn kits, teach them to use it & distribute. Teach them to diaper their babies. Bathing of babies can be added (adjacent to this station if time and circumstances permit). e. Review action items. SPECIAL NOTE: If a family has more severe problems than initially thought, it is up to the screening nurse and health workers to identify this and use a marker to put a large colored mark across the front and back of their card and make sure they get directed to go back over to the medical registration table and get in to see the doctor. Staff permitting, a nurse or doctor can take the patient(s) that need medical attention and set up a small table with medications. These patients can be treated in a designated area outside the medical tent, thus not impeding the flow in the medical tent.

More About Patient Traffic Flow Traffic flow coordinators should be stationed to check cards and direct patients through the waiting area teaching stations into either the medical room or the enclosed teaching tent area as flow dictates. If entrances and exits are on the same side, the traffic flow coordinators should also direct patients out, once their card has been completed and collect the card from the patient. If there is another door (or opening in the tent) being used for exit, there should be another traffic flow coordinator on the exit side. The number of people coming to be treated or receive training and hygiene supplies will dictate whether one, two, three or even four traffic flow coordinators are required.

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3. Medical Room / Dispensary Since patients have already been pre-screened, only those with colored cards are brought to the medical room. Health care workers should work side-by-side with medical professionals in the medical room whenever possible and appropriate. The diagnosis and treatment should be discussed with the health worker and the medical professional should empower the health worker to deliver the diagnosis and treatment whenever appropriate. The room generally has at least two tables for the dispensary, and several desks or chairs for the treatment stations. It is also ideal if a mattress with plastic cover is available for patients who need to lay down with sheets (curtains) hung for privacy. Entrance/exit areas should be roped off, with appropriate roped walkway access from the training/triage area and waiting area.

4. Health Worker Training

Health worker training consists of two main parts: classroom training (which is limited to one day) and hands-on training (which is three days). Rotation of health workers through various areas Â check-in, teaching stations, triage and medical room is important to enabling them to receive a wide variety of experiences. Classroom Training Advance prep: Work with in-country facilitators to identify the following: 1) names of the health workers with village location, 2) past training if any, 3) materials in their possession i.e. Where There is No Doctor, Good Health Begins at Home, 4) whether they have a Health Worker ID card, 5) requested areas for additional training. Two translators are needed for the joint classroom morning. Ideally, this is done well in advance of the expeditionâ&#x20AC;&#x2122;s departure so that preparation can be customized to needs. ID name cards, plastic holders and lanyards should be prepared in advance. (Photos can be added, and names printed out on site with a label maker during the course of the classroom training morning). A limited number of topics should be prepared to discuss with the health workers for the first classroom training morning, and should focus on three important aspects: 1. Identifying priorities (as identified by the health workers) that they want to discuss /learn during the week. 2. Reviewing the clinic protocol, discussing the health worker's roles and setting up rotation schedules for the next three days. The health workers should have a good understanding of how the clinic will work / flow.

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3. The health workers should then spend the remainder of the morning getting prepared and actually practicing their teaching (for the six teaching stations). The two translators should work with them to help them prepare. Experience with health workers in Africa, Asia and Latin America has shown that even health workers who have had government training seem to be ill-prepared (and/or very shy) about teaching and being assertive to help their communities. They lack confidence and an understanding of how to teach and help their fellow villagers. Thus, they have a difficult time being effective in their communities, even though they have knowledge and skills to share. This preparation for teaching, followed by 3 days of practical experience with teaching, diagnosis, triage, and clinic will be the most important thing accomplished by the health team. Empowering the health workers to learn and practice their skills so they can carry on successfully after the expedition is our number one priority. Hands-On Training / Clinic Here are the hands-on stations, which when possible should be staffed by and rotated among the health workers. 18 health workers for the rotation can be kept busy. Expedition members can man some stations rather than health workers should there be a smaller number of health workers available, or should the hand-on training be scheduled to rotate with classroom sessions. Latin American clinics are generally smaller and less demanding than African Clinics-which can be huge and non-stop! 1. Check-in / Registration: five health workers, two translators (and two expedition participants to help get things going). The two registration stations could be manned without health workers if necessary, since there are translators planned for these stations. 2. Seven teaching stations: Seven health workers, with expedition health team members assisting as needed (translators should not be necessary if teaching preparation was thorough and if adequate health workers are available for teaching). These teaching opportunities should be high priority for utilizing health workers. 3. Medical room / Dispensary: 1 to 4 health workers (1 to 3 for treatment stations working with 2 or 3 docs or nurses, and possibly 1 for dispensing meds). 4 translators and one or two health team members are also needed for the dispensary. Important Additional Training: Village Health Committee Organization and Health Worker Responsibilities. During the week, as the health workers rotate between clinic, teaching stations and additional classroom teaching, it is important to make certain to schedule rotations for the health workers to discuss organization of village health committees, how the health workers function in their communities / recommendations for improvement (or how to get organized if no organization exists), and expectations of Ascend for the village health workers, including reviewing the procedures, forms and rewards for completing semi足annual surveys of their assigned village families.

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Section 4. Establishing Expeditions With Surgeons And Other Professionals It is critical to communicate with our country leaders about who we have on our team and what specialty they bring to avoid confusion. Our medical system in the USA also has created many different specialists such as Orthopedic Hand surgeons that do not exist in the countries we visit. Matching up these specialists with doctors that have similar interests or at least with those who could benefit from our association is critical to the success of our visits. Medical / Surgical Team Organization Level One - Surgical team that includes one or more surgeons and all the support staff, equipment and supplies that would be needed to conduct surgical intervention independent of any support in country. Purpose; This is the approach necessary in areas where there are no Doctors. Treat as many patients as possible in a short time. Level Two - Surgical team that includes one or more surgeons and partial team of support staff, equipment and supplies. The team filled in by non-medical volunteers, local doctors and provides. Local resources of supplies are also needed to fill in the gaps for team needs. Purpose; Level two can do more good because of the initial involvement of local healthcare providers (assuming the area has providers). The ultimate goal here is to set up ongoing health care campaigns with local providers. Level Three - â&#x20AC;&#x153;Simpleâ&#x20AC;? surgical team that includes one or more surgeons and a few support staff. Equipment and supplies are carefully chosen to support surgical interventions during the expedition as a team effort with local doctors. Support of local health care includes instruction, conferences, clinical sounds, discussions, and cooperative medical/surgical interventions with patients of the local health care or system. Purpose; Support and enhance local surgical team efforts. Note: There are differences in the goals one is seeking to achieve when choosing to conduct Medical/Surgical interventions using any one of the three levels of Team Organization. We wish to attain the third level team organization for its obvious legacy building and efficient resource utilization. In recent years troubling levels of medical malpractice threats models after the United States fiasco have crept into South America and have caused us to be very cautious when treating patients as the primary provider. It is increasingly necessary for us to adopt an advisory capacity to serve our locally established teams.

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Important tasks setting up a surgical team 1. Educate your surgical team on what to expect in country. Erase from their minds incorrect expectations. 2. Team members are always going to ask, “What can I do to get ready? What do I need to bring? Etc. Answers to these questions; a. Even if you were “beamed into the country with just the shirt on your back, you would have a good experience and the teams in country would benefit from your knowledge expertise and presence. Bring equipment that you can leave with them. What do they need? Everything! Keep simple and light enough to pack for airlines. Consider customs problems. b. Bring a good attitude. Not everything will go as you expect. You should consider each a day helping a local doctor understand some of new ways of doing things or your discovery of their needs will be greater service than practicing your surgical skills on a needy patient. Only you and your specialized skill and knowledge can promote this kind of success. 3. Make sure that a previous surgeon’s experience from past expeditions is transferred to your surgeon(s). Failure to do this negates any gains made in knowledge from initial discovery. Our growing understanding of the medical needs in a country is valuable resource details that should not be treated lightly. 4. Organize the surgical team so that everyone has a task. It is not good for anyone to spend too much time in surgery observing. Many may want observe surgery but this should be rotated so that the team member gets other experiences outside the operating room. 5. Bring surgical gowns and gloves, sutures, mesh, etc. and especially surgical equipment. Medical equipment salesmen look for opportunities to divest themselves of surplus equipment. It can be very valuable to our teams in country. 6. Cold sterilization supplies can be very valuable to make o ur equipment available for more than one or two surgeries per day. Local sterilization techniques may take many hours to complete. 7. Bring shoe covers, hats and masks. These items seem to be in short supply. 8. Surgical textbooks, pamphlets, videos etc., can be very valuable to local surgeons. Most understand English and or read it but do not speak it well. 9. In-country teams should ask local administrators and surgeons if they require licenses and CVs of our Doctors and Nurses. 10. Be careful of administrators who wish to rent us the operating room. We should not be using valuable resources held hostage by corrupt administrators looking for money. Most hospitals are so grateful for the supplies we donate that they would never consider charging us. Some have even refused to charge us for the use of their supplies.

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11. Operating rooms in South America always need scrubs and cloth drapes 12. Schedule in-service education with the local equivalent of your team’s nurses, surgical techs etc. Make them fun and serve food! 13. Invite all locals who have participated with you to a dinner towards the end of the expedition. Make certificates or awards of appreciation. These may seem “cheesy” but are valued by them as tokens of friendship. They may do this for you as well. 14. Never have the attitude that “we are smarter” or “we are better”. 15. Our surgeons make think they have wasted their time if they have not been set up to perform their excellent surgical skills. Some say if we cannot use their unique skills they feel useless. There are many humanitarian organizations that operate at level one and would keep such surgeons busy day and night. Remind these surgeons that have a unique opportunity to help the local providers reach a higher ability. Their efforts may sometimes seem small. We have seen incredible strides from simple experiences shared between one of our surgeons and a local doctor. Examples are; a. b. c. d.

Planning a first time ever Emergency Medicine residency program. Simple pediatric anesthesia training saves lives of all children under 1 in hospital. Patients no longer die because external fixation principles are revised. Internal fixation of facial features releases patients from hospital in 24 hours instead of days in ICU then death. e. Incorrect techniques used by oral surgeons killing patients…, proper techniques demonstrated and accepted. f. Numerous examples of equipment delivered and put into use with proper training.

Important consideration when working with Hospitals Local Hospitals should understand that unlike other humanitarian teams, we are not there to take over their rooms, use their supplies, and leave them holding the bill. We are there to do surgery with them. We should offer to help with supplies and cover the costs of supplies we cost them to use because of our attendance. If our teams bring in needy cases from our clinics, we should pay for them.

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Packing List: Medications and Supplies

As a minimum, the following list of medications are needed on each Medical expedition: 1. Cipro 500mg. 2. Cipro 1000mg. 3. Keflex 500mg 4. Doxycycline 100mg 5. Amoxicillin 250mg Susp. 6. Amoxicillin 500mg Susp. 7. Amoxicillin 250mg capsules 8. Mebendazole – Worms 9. Tinidazole 500mg – Amoeba 10. Laridox - Malaria – depending on region 11. Cholorquine – Malaria – depending on region 12. Anti-fungal cream 13. Anti-bacterial cream 14. A & D ointment 15. Ibuprophen liquid for infants 16. Ibuprophen for adults 17. Tums 18. Tylenol 19. Vitamins – children 20. Vitamins – pre-natal 21. Vitamins – adult 22. Cotrimox 160/800 23. Benzoyl benzoate lotion – scabies 24. Soap – can be purchased in-country 25. IM antibiotics 26. Antibiotic ear drops 27. Antibiotic eye drops 28. IM Phenergan Most all of the above medications can be purchased in Peru by Ascend. However it is always best to check with the suppliers and donors first. The In-Country Director can do the ordering for medication once supplies are agreed upon. This prevents duplication and confusion and allows for consistency. Medication costs are one of Ascend’s biggest expenses. Most often, these costs can be supported through donations. Ascend encourages every participant to reach out to any contact they might have for any medication donations on above medications list above and the supplies list below. Medication orders for the Ascend In-Country Director need to be placed four weeks prior to an expedition. This allows ample time to contact different pharmacies and find a competitive price.

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It is also recognized that there are other medications that may be needed or preferred by certain medical professionals, and these can certainly be added to the list. The lists above and below represent those medications and supplies that have proven to be most needed on previous expeditions. As a minimum, the following list of supplies are needed on each expedition: 1. Surgical instruments 2. Otoscope – one for each medical personnel 3. Ophthalmoscope – one for each medical personnel 4. Stethoscope – one for each medical personnel 5. Bandaging supplies – Gauze, tape, Kerlix, 4x4, etc. 6. Tape – the white sports tape is best but plastic and paper can also be used. 7. Sutures and suturing equipment 8. Bandage scissors 9. Gloves 10. Paper gowns 11. Betadyne swabs – for cleaning wounds 12. Surgical scrub brushes – type used in the OR - (10-20) 13. Plastic basins/ bowels (4-5) for cleaning wounds etc. 14. Medication dosing cups/10cc syringes for dosing meds 15. Sharps container (small) Zip lock baggies – one gallon and sandwich size (several hundred) 16. Hand sanitizer - to be used in between hand washings 17. Plastic sheets (10-15) 18. Paper towels 19. Ear curettes 20. 20-30-cc syringes for irrigation 21. Sterile needles (5 of each, 25 ga, 30ga) for foreign body removal 22. 1 vial Lidocaine w/epi 23. 1 vial Lidocaine w/o epi. 24. Ace wraps 25. Eye wash (boric acid) 26. Plastic speculums (2-3) Please coordinate with Ascend staff concerning which items will need to be brought with the medical team and which can be supplied in country. Medical personnel are encouraged to bring their own instruments, otoscope, ophthalmoscope, and scissors, etc. to use on the expedition. These can either be donated or taken home after the expedition.

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Examples Of Successful Clinic Projects In Peru And Bolivia

Riding horseback into high Andean Villages to conduct Medical and non-medical activities Using big puppets to teach dental health to school children and villagers Puppet shows to teach children and villagers while they wait in line for medical care Requiring villagers to do service with us or give food for services rendered Requesting school assembly and performance of dances and songs (they love to do this for us) This follows the principle that if you want to someoneâ&#x20AC;&#x2122;s friendship, ask them to do something for you Visiting Orphanages and setting up First Aid Kits with instructions to staff. Teaching stations in local facility covering first aid, dental health, nutrition etc., taught to local village leaders Working with Peruvian ministry of health officials volunteering our services in areas of need. Schools for wayward youth etc. Setting up clinics within the villages under the care and projects of other humanitarian teams who could use our help. Soccer matches with local villagers in the afternoon after medical clinics Teaching local interested villages to help with the reading glass station during clinic medical campaigns. Never giving out anything for free. Especially soap, toys, dolls, blankets. This must be well controlled by the principle that they must do something to receive something. Village leaders can be consulted if certain members of the village need extra assistance. Tickets or tokens help control and organize this.

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Medical Surgical Team Positions

Surgical squads: Surgeon Assistant Head Nurse Hospital/Administration Agent Circulating Nurse Surgical Technician Roaming Translator Surgeonâ&#x20AC;&#x2122;s Translator Photographer/ Historian/ note taker Engineer

Clinic Team: Doctors and Dentists Head Nurse Registration agents Triage Nurses Doctors and Dental assistants Sterilization and equipment specialists Pharmacist and Pharmacy techs Runners Translators Engineer Photographer/Historian/note taker Clinic/ Administration Agent Puppet Show team Dental Health Teaching team

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Other Health Care Resources Available

1. Family Health Manual – Our family health manual is available in English and Spanish and contains descriptions and remedies for common illnesses. Can be used to make great laminated takeaway cards for teaching stations and the manual can be printed and distributed to families. 2. Hand out instruction cards for kits/teaching stations – We have a collection of handouts ranging from hand-washing post-ups and nutrition pyramids to posters about skin protection, hygiene, tooth brushing, and more. Contact Ascend Travel for details. 3. Pro-literacy Worldwide manual “Good Health Begins at Home” – This manual, available in English and Spanish, was created with the purpose of creating a dialogue and getting people aware of their health. Great resource for health education workshops and teaching ideas. 4. Where There is No Doctor - The most widely used health care manual for health workers, educators, and others involved in primary health care delivery and health promotion programs around the world. Current edition contains updated information on malaria, HIV, and more. Available from Ascend or online at hesperian.org/books-and-resources/. 5. Helping Health Workers Learn - An indispensable resource for health educators, this book shows – with hundreds of methods, aids and learning strategies – how to make health education engaging and effective, and how to encourage community involvement through participatory education. Available from Ascend or online at hesperian.org/books-and-resources/. 6. Where Women Have No Doctor - An essential resource for any woman or health worker who wants to improve her health and the health of her community, and for anyone to learn about problems that affect women differently from men. Topics include reproductive health, concerns of girls and older women, violence, mental health, and more. Available from Ascend or online at hesperian.org/books-and-resources/.

* Antibiotic/Disease Cross-Reference, Sample Forms, Tent Layout and for Health Care Screening and Control are included as attachments to this manual.

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Appendix I: Antibiotic/Disease Cross-Reference Amoxicillin • UTI (250mg tid x35d) • Pneumonia (500mg tid x 7-14d; 2040mg/kg/d div bidtid) • Typhoid (500mg qid x2 wk; 100mg/kg/d div qid) • Gonorrhea (3G x 1) • Ear/sinus inf. (250500mg bid-tid x 57d; 20-40mg/kg/d div bid-tid) • Unexplained neonatal inf. (30mg/kg/ d div bidtid) • Dental inf. (500mg tid x 7-10d; 2040mg/kg/d div bid tid) Cautions/ Contraindications (other than allergy)

Cephalexin • UTI (500mg bid x 7-10d; 2550mg/kg/d div qid) • Skin infections (500mg bid x 5-7d; 25-50mg/kg/d div qid) • Pneumonia (500mg bid x 14d; 2550mg/kg/d div qid) • Ear/sinus inf.)(250500mg bid x 14d; 25-50mg/kg/d div qid) • Dental inf. (500mg bid x 7-10d; 2550mg/kg/d div qid) Cautions/ Contraindications (other than allergy)

Trimethoprim/sulfa DS=160/800; SS=80/400; 40 /200/5ml • Typhoid (1 DS or 2 SS bid x 7-14d; 6-10mg/kg/d TMP div bid) • Dysentery (1 DS or 2 SS bid x 3 d; 6-10mg/kg/d TMP div bid) • Cholera (8mg/kg/d TMP div bid x 3d) • Gonorrhea (21/2 DS or 5 SS 5x/d x 2-3d) • Skin infections (1 DS or 2 SS bid x 7d; 6-10mg/kg/d • Ear/sinus inf. (1 DS or 2 SS bid x 7d; 6-10mg/kg/d) • Pneumonia (1 DS or 2 SS bid x 7d; 6-10mg/kg/d TMP div bid) • UTI (1 DS or 2 SS bid x 5d; 6-10mg/kg/d) • Skin inf. (1 DS or 2 SS bid x 5-7d; 6-10mg/kg/d) • Dental inf. (1 DS or 2 SS bid x 5-7d; 6-10mg/kg/d) Cautions/ Contraindications (other than allergy) • < 2 mo. • Try to find alternate < 1 y • 3rd trimester preg. • Take w/ ééwater

Doxycycline

Ciprofloxin

Zithromax

• Relapsing fever (100mg bid x 7d; 10 mg/kg qid >8y) • Typhus (100mg bid x 7d; 10 mg/kg qid>8y) • Cholera (100mg bid x 3d) • Chlamydia (100mg bid x 7d) • Gonorrhea (100mg bid x 7d) • PID (100mg bid x 1014d) • Sinus (100mg bid x 7d) • Malaria (prevention only 100 mg qd) • Pneumonia (100mg bid x 7d; 10 mg/kg qid>8y)

• UTI (250mg bid x 3d) • Skin infections (500mg bid x 5-7d) • Gonorrhea (500mg x 1) • PID (500 bid x 14d) • Dysentery (500mg bid x 3-5d) • Chlamydia (500mg bid x 14d) • Typhoid (500mg bid x 2 wk) • Pneumonia (500mg bid x 7d)

• Pneumonia (Zpack or 500mg qd x 3d; 10mg/kg qd x 3d >6mo) • Chlamydia (1G x 1) • Gonorrhea (2G x 1) • Relapsing fever (Zpack or 500mg qd x 3d; 10mg/kg qd x 3d >6 mo) • Endomyometritis (500mg qd x 10d) • Dysentery (Zpack or 500mg qd x 3d; 10 mg/kg qd x 3d >6 mo) • Skin infections (Zpack or 500mg qd x 3d; 10mg/kg qd x 3d >6 mo) • Ear/sinus inf. (Zpack or 500mg qd x 3d; 10mg/kg qd x 3d >6 mo)

Cautions/ Contraindications (other than allergy) • < 8y • pregnancy • ? safety w/ nursing

Cautions/ Contraindications (other than allergy) • ? safety w/ nursing • é effect of caffeine

Cautions/ Contraindications (other than allergy) • <6 mo. • ? safety w/ nursing

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Laridox • Malaria (1/4 tab 2-11 mo; 1/2 tab 1-3 y; 1 tab 4-8 y; 2 tab 9-14 y; 3 tab >14 y) Cautions/ Contraindications (other than allergy) • Sulfa allergy • ? safety w/ nursing

Mebendazole • Worms (all) (100mg bid x 3d adult & child) Cautions/ Contraindications (other than allergy) • Pregnancy •<2y

Tinidazole

Metronidazole

Benzyl benzoate

• Amoeba &/or Giardia (500mg 2 tab bid x 3 d adult; 50-60mg/kg qd x 3d child)

• Giardia (250mg tid x 5d; 5mg/kg tid) • Amoeba (750mg tid x 510d; 35-50mg/kg/d div tid • Vaginitis (500mg bid x 7d)

• Scabies &/or Lice (Apply at night; wash in am x 3d)

Cautions/ Contraindications (other than allergy) • 1st trimester preg. • Nursing

Cautions/ Contraindications (other than allergy) • 1st trimester preg. • Nursing (discard milk until 24h after finishing) • Liver probs.

Cautions/ Contraindications (other than allergy)

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Field Medical Clinic Treatment & Tracking Tool

URGENT PINK CARDS Print 2-sided on PINK card

ONE PER FAMILY, CHECK / LIST ONLY THOSE PRESENT: Family Name:

Village where they live:

Father-age:

Complaints(C’s):

Guardian-age:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Child-age:

M or F

C’s

Child-age:

M or F

C’s

Child-age:

M or F

C’s

Child-age:

M or F

C’s

C’s:

_________________________________________________________________________________________________________________ Teaching stations:

#1 Respiratory

#2 Hygiene

#3 STD’s

#4 Skin care

#5 gastrointestinal

# 6 Nutrition, maternal & Newborn

Diagnoses: Malnutrition-dry: small, thin, wasted; starving Malnutrition-wet: swollen feet, hands, face; color loss in hair, skin, protein & vitamin deficent Malaria: Recurring fever, shaking chills ,headache, muscle aches Relapsing fever: sudden high fever, chills, headache, body ache, cough; spleno&hepatomegaly Typhus: begins like URI, then in 1 week, fever, rash(looks like many tiny bruises Typhoid: headache, sore throat, dry cough, fevers, rash, vomiting, diarrhea Worms: bloated abd., stomach pain, visible in stools or emesis Amoeba: diarrhea+blood-fever Giardia: severe bloating, no blood Shingella (dysentery): -diarrhea +blood + fever Cholera: rice water stools

URI (upper resp. inf.): – runny nose, ST, cough, no fever Otitis Media(om): pain, fever, red, bulging tM; d/c if ruptured; often seen with Sinusitus

Pharmacy Rx:

Qty:

Supplies/ Instructions Increase food, any kind, vitamins Increase fresh and protein-rich foods, vitamins

Laridox (pyrimethamine & sulfadoxione) ¼ tab 211 months/ ½ tab1-3 years, 1 tab 4-8 years, 2 tab 9-14 years, 3 tab 14+years Doxycycline 100-200 mg x 1 Doxycycline 100-200 mg x 1 Doxy 100 mg bid x 2 weeks adult; 50 mg 8-12y (not for child<8y) OR Cipro 500 mg bid x 3 d; 20-30 mg/kg/ div q 12h child Mebendazole(Wormin/Vermox) 100mg bid x 3d adult & child (not for <2y & pregnant) Tinidazole 500mg bi x 3 d adult 50-60 mg/kg qd x 3 d child Tinidazole 500mg bi x 3 d adult 50-60 mg/kg qd x 3 d child Cipro 500mg bid x 3 d; 20-30 mg/kg div q 12h child OR Cotrimox 160/800 bid x 5 d adult; 6-10 mg/kg (TMP) div q 6-8 child x 5-7 d Doxy 300 mg bid x 3 d adult; 50-100 mg bid x 3 d 8-12 y(not for child 8<y) OR Cipro 500 mg bid x 3 d; 20-30 mg/kg div q 12h x 3d child OR Cortimox 160/800 bid x 3 d adult; 6-10 mg/kg (TMP) div q 6-8 h x 3d child

Mosquito protection-bednets screens 1) needs fluids to tolerate hypotensive effect of treatment 2) delouse family 1) needs fluids to tolerate hypotensive effect of treatment 2) delouse family 1) ORS & home inst. 2) boil or filter water 1) boil or filter water 2) ORS & home inst. 1) boil or filter water 2) ORS & home inst. 1) boil or filter water 2) ORS & home inst. 1) ORS & home inst. 2) boil or filter water 1) ORS & home inst. 2) boil or filter water

Cold, cough remedies & home inst. Amox 250 mg tid x 5d adult; 25-50 mg/kg/d div q 8-12h x 5-7d child OR Cotrimox 160/800 bid x 5 d adult; 6-10 mg/kg(TMP) div q 6-8 h child x 5-7d OR

Pain pack & home inst.

Sinussitis: purulent nasal d/c > 2 weeks, face pain, fever

Otitis externa: pain w/ ear tug, draining pus; may be 2° OM, impacted wax or foreign body Chronic cough: occurs w/ URI, allergies, or irritants Pneumonia: fever, productive cough w/ green, yellow or bloody sputum -raid breathing, chest pain, looks ill

Eye infection: pain, red conjunctiva, green d/c STD: women-abd. Pain, abnl bleeding w/sex -men-painful urination, discharge from penis Vaginitis: itching, or change in discharge UTI: painful, frequent urination Kidney infection: -flank pain, fever, blood in urine Scabies: small, itchy bumps on feet, legs, hands, forearms, genitals; may become infected Lice: tiny black bugs w/sand-like nits sticking to hair shaft; assoc w/ relapsing fever & typhus Bacterial skin infection: Swelling, redness, oozing pus, or honey colored crusting -small wounds treated effectively w/ topical abs; more severe needs systemic - consider other c\!!!! need to look at guide can’t read this goddamn sentence Fungal skin inf. : red scaley patches –may have central cleaning(clearing)!!! Dermatitis/ eczema: dry, red, itchy patches, seen in skin folds, flexures Dental infection: severe pain & swelling of the jaw, home remedy

Filariasis: attacks of painful swelling of foot, gradually rising into the groin- elephantiasisto the hospital TB lungs, lymph nodes: persistent cough, sputum w/blood, night sweats, fatigue, wt. Loss Congential/ malform:

Cephalexin 500 mg bid x 5d adult; 25-50 mg/kg/d div q 8-12h x 5-7d child Amox 250 mg tid x 5d adult; 25-50 mg/kg/d div q 8-12h x 5-7d child OR Cotrimox 160/800 bid x 5 d adult; 6-10 mg/kg(TMP) div q 6-8 h child x 5-7d OR Cephalexin 500 mg bid x 5d adult; 25-50 mg/kg/d div q 8-12h x 5-7d child Antibacterial ear drops (any) 3 times/day; if pain severe & TM not seen, treat as for OM

Pain pack & home inst.

Ear wash & home inst. Cold, cough, fever remedies & home inst.

Amox 250-500 mg tid x 7-10d adult; 25-50 mg/kg/d div q 8-12h OR Cotrimox 160/800 bid x 7-10d adult; 6-10 mg/kg/(TMP) div q 6-8 h child x 57-10d OR Cipro 500 mg bid x 7-10 d; 20-30 mg/kg div q 12h x 7-10d child

Cough syrup; home inst.

Antibacterial eye drops bid-tid x 5d

Eye wash & home inst.

Cipro 500 mg x 1 AND 100 mg bid x 7d # partners to be treated Metronidazole 500mg bid x 5d OR Miconazole cream intravaginally x 5-7 d Cipro 500 mg bid x 3d (7d if kidney) OR Cotrimox 160/800 bid x 3d (7d if kidney) Cipro 500 mg bid x 3d (7d if kidney) OR Cotrimox 160/800 bid x 3d (7d if kidney) Benzoyl benzoate lotion-apply to entire body before bed: wash off in AM; repeat 3 nights in a row AND/OR tetmasol soap used regularly Benzoyl benzoate lotion-apply to entire body before bed: wash off in AM; repeat 3 nights in a row AND/OR tetmasol soap used regularly Antibiotic cream bid until healed OR Amox 250 mg tid x 5d adult; 25-50 mg/kg/d div q 8-12h x 5-7 child OR Cotrimox 160/800 bid x 5 d adult; 6-10 mk/kg(TMP) div q 6-8 h child x 5-7d OR Cephalexin 500 mg bid x 5d adult; 25-50 mg/kg/d div q 8-12h x 5-7d child Antifungal cream bid until healed

Increase fluids, ORS inst.

Steroid cream bid PM

Moisturizer/ A&D oint

Amox 250 mg tid x 5-7 adult; 25-50 mg/kg/d div q 8-12 x 5-7d child OR Cotrimox 160/800 bid x 5-7d adult; 6-10 mg/kg (TMP) div q 6-8 h child x 5-7d OR Cephalexin 500 mg bid x 5-7d adult; 25-50 mg/kg/d div q 8-12h x 5-7d child Refer to clinic or hospital

Pain remedies & teeth hygiene home inst.

Increase fluids, ORS inst. Bedding and clothes cleaning inst ; treat whole family Fine tooth comb; bedding & clothes cleaning inst ; treat whole family Gauze and wood cleaning supplies -stress hygiene

Stress hygiene

Ace wrap, soap, washcloth w/ foot care instructions

Refer to clinic or hospital Refer to clinic or hospital

Heartburn

Heartburn home remedies

Pain (muscle, head)

Pain remedies & pain pack

Other diagnoses & treatment instructions:

Sent to medical tent Sent to dentist

Prepackaged medication packs available: Pain Pack: Tylenol/paracetamol/acetaminophen with home care instructions- 500 mg-1Gm q 6h adult; 500 mg 8-12y; 250 mg 3-7y; 125 mg 1-2y; 63 mg <1y Skin care pack: Chapstick, medicated lotion, Tetmasol soap

Cold care/ Oral Rehydration: Spoon & instructions for nose drops, cough syrup, oral rehydration formula. May also include salt & sugar if need is great enough Heartburn pack: Antacids with home remedy instructions

Field Medical Clinic Treatment & Tracking Tool

NON-URGENT WHITE CARDS Print 2-sided on white card Stock, cut in half

ONE PER FAMILY, CHECK / LIST ONLY THOSE PRESENT: Family Name:

Village where they live:

Father-age:

Complaints(C’s):

Guardian-age:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Child-age:

M or F

C’s

Child-age:

M or F

C’s

Child-age:

M or F

C’s

Child-age:

M or F

C’s

C’s:

_________________________________________________________________________________________________________________ Teaching stations:

#1 Respiratory

#2 Hygiene

#3 STD’s

#4 Skin care

#5 gastrointestinal

# 6 Nutrition, maternal & Newborn

Diagnoses: Worms: bloated abd., stomach pain, visible in stools or emesis URI (upper resp. inf.): – runny nose, ST, cough, no fever Chronic cough: occurs w/ URI, allergies, or irritants Eye irritation: pain, red conjunctiva, green d/c Scabies: small, itchy bumps on feet, legs, hands, forearms, genitals; may become infected Lice: tiny black bugs w/sand-like nits sticking to hair shaft; assoc w/ relapsing fever & typhus Mild skin infection: mild swelling, redness, oozing pus, or honey colored crusting Dry, irritated skin: dry, red itchy patches Toothache: without severe swelling of the jaw Heartburn

Pharmacy Rx: Mebendazole(Wormin/Vermox) 100mg bid x 3d adult & child (not for <2y & pregnant)

Supplies/ Instructions 1) boil or filter water 2) ORS & home inst.

Cold, cough remedies & home inst.

Cold, cough, fever remedies & home inst. 1) Eye wash & home inst.

Benzoyl benzoate lotion-apply to entire body before bed: wash off in AM; repeat 3 nights in a row AND/OR tetmasol soap used regularly Benzoyl benzoate lotion-apply to entire body before bed: wash off in AM; repeat 3 nights in a row AND/OR tetmasol soap used regularly

Pain: (muscle, head) Other diagnoses & treatment instructions:

Qty:

Bedding and clothes cleaning inst ; treat whole family

Fine tooth comb; bedding & clothes cleaning inst ; treat whole family

Gauze and wound cleaning supplies & stress hygiene

Moisturizer/ A&D ointment

Pain remedy & tooth hygiene inst

Heartburn home remedies

Pain remedies & pain pack

Sent to medical tent Sent to dentist

Pharmacy Rx: Mebendazole(Wormin/Vermox) 100mg bid x 3d adult & child (not for <2y & pregnant)

Supplies/ Instructions 1) boil or filter water 2) ORS & home inst.

Cold, cough remedies & home inst.

Cold, cough, fever remedies & home inst. 1) Eye wash & home inst.

Pain: (muscle, head) Other diagnoses & treatment instructions:

Qty:

Bedding and clothes cleaning inst ; treat whole family

Fine tooth comb; bedding & clothes cleaning inst ; treat whole family

Gauze and wound cleaning supplies & stress hygiene

Moisturizer/ A&D ointment

Pain remedy & tooth hygiene inst

Heartburn home remedies

Pain remedies & pain pack

Sent to medical tent Sent to dentist

Field Medical Clinic Treatment & Tracking Tool

NON-URGENT WHITE CARDS Print 2-sided on white card Stock, cut in half

ONE PER FAMILY, CHECK / LIST ONLY THOSE PRESENT: Family Name:

Village where they live:

Father-age:

Complaints(C’s):

Guardian-age:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Mother-age:

Pregnant: Y or N

Nursing: Y or N

Has Newborn: Y or N

C’s:

Child-age:

M or F

C’s

Child-age:

M or F

C’s

Child-age:

M or F

C’s

Child-age:

M or F

C’s

C’s:

_________________________________________________________________________________________________________________ #1 Respiratory

#2 Hygiene

#3 STD’s

#4 Skin care

#5 gastrointestinal

# 6 Nutrition, maternal & Newborn

Dosing Instruction Diagram

Tres veces al día Mañana Medio Día Cuando Tomar

Cuantas cada vez?

Cuatro veces al día Noche

Tarde

Cuantas cada vez?

Mañana Medio Día

Cuantas cada vez?

Mañana Medio Día

Noche

Tarde

Noche

Una vez al día Noche

Tarde

Cuando Tomar

Cuantas cada vez?

Indicaciones personalizables Cuando Tomar

Tarde

Cuantas cada vez?

Dos veces al día Cuando Tomar

Mañana Medio Día Cuando Tomar

Noche

Mañana Medio Día

Thank You! Your participation in Ascend Travel is what makes our life changing efforts possible. We hope that this briefing manual has been informative and answered the majority of your questions prior to departure. The most important considerations before visiting Peru are keeping an open mind and being ready for a variety of different situations. At Ascend, we are dedicated to providing an exceptional adventure as we provide educational, health, microenterprise, and simple technology solutions to those in need. We look forward to seeing you in-country and helping facilitate the experience of a lifetime. With the most sincere thanks,

Av. Tullumayu, Nº280 Cusco, Cusco, Peru Phone: 51-084-436020 Web: www.ascendtravelperu.com Email: info@ascendtravelperu.com

Timothy Marti CEO and Founder

“Before the trip there was a lot of talk about going to Machu Picchu, and how cool that was going to be, and yes we did have a great experience at Machu Picchu, but in talking to our children after the trip they unanimously said that the real treat of the trip was living and working in the village amongst the Peruvian people. We all can’t wait to go back!” -John Edwards, 2011

Solutions for Ending Poverty and Creating a Brighter Future