Sample Clinic Operations and Provider Call · Hi everybody, this is Amy, I'm with International...

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Sample Clinic Operations and Provider Call Amy Jordheim: Hello everybody. Sarah: Hello. Amy Jordheim: Hi this is Amy, I'm with International Medical Relief. Sarah: I'm in Wisconsin, this is Sarah Arndt. Amy Jordheim: Hi Sarah, how are you? Sarah: Good, how are you doing? Amy Jordheim: I'm doing great, thanks. Hi everybody, you're on the line for the Clinic Operations and Provider Call with International Medical Relief. Amy Jordheim: You can say hello. Loveland: Oh hi, this is [Loveland 00:00:42]. Amy Jordheim: Hi, how are you? Loveland: Yes, how are you ma'am? Amy Jordheim: Doing great, my name is Amy and I'm with International Medical Relief. I'm gonna lead this portion of the call, and then at 7:30, the IMR Medical Director, Dr. William Hughes, will be on to talk about provider guidelines, and philosophy with which we use to treat patients. Loveland: Okay, thank you ma'am. Amy Jordheim: Sure. Hi, who jumped on? Erin: Erin, from Cincinnati, Ohio. Amy Jordheim: Hi Erin, how are you? Erin: I'm good, how are you?


Amy Jordheim: Good, this is Amy, I'm with International Medical Relief. We're gonna give people about two more minutes to jump on, I hear a lot of beeps coming in, so you have a couple more minutes before we're gonna get started. Erin: Okay. Amy Jordheim: Anybody have any questions that I can answer, while we're waiting? Loveland: Hi Miss Amy, this is Loveland. Amy Jordheim: Hi Loveland, how are you? Loveland: I am good. I just have a question with regards to the [inaudible 00:01:50], do we need to bring up [inaudible 00:01:53]? Amy Jordheim: What trip are you on? Loveland: Himalayan expedition. Amy Jordheim: You need to talk to David Bop about all of the supplies that are required. Loveland: Okay. Amy Jordheim: So I will refer you to that, which will ... Loveland: Okay, yeah. Amy Jordheim: Hi everybody, sorry, I don't know what happened, but my phone dropped. Loveland, I was asking if you would like an email? Loveland: Yeah, I can just send him an email. Amy Jordheim: Or would you like me to send you an email with his phone number on it? Loveland: Yeah that would be great ma'am. Amy Jordheim: Sure, do you have the packing list for that trip?


Loveland: What is that? Amy Jordheim: Do you have the packing list for the Himalayan [inaudible 00:03:24]? Speaker 6: Hello? Amy Jordheim: Hi, just one second. Loveland: I have [crosstalk 00:03:29] Yes, I have the list ma'am, but I'm not sure which ... [inaudible 00:03:39] check. Amy Jordheim: Okay. Well I will send you an email with his number, but you need to talk to him. It's a very specialized trip as far as the requirements go. Loveland: Thank you. Amy Jordheim: Yeah, you [crosstalk 00:04:04] training too, right? Loveland: We need physical trainings? Amy Jordheim: Uh-huh (affirmative), because it's a trekking trip. Loveland: Yes ma'am I [crosstalk 00:04:17] Amy Jordheim: Good, well I'm gonna send an email to both of you so that you guys can get in touch, how about that? Loveland: Yes, thank you. Amy Jordheim: Great, thank you. Hi everybody, this is Amy, I'm with International Medical Relief. Speaker 6: Hello. Amy Jordheim: Tonight his the Clinic Operations call and the Provider Call. I'm just giving people another half minute to jump on, then we'll get started talking about clinic operations. Speaker 6: Oh good, I just got on, I was thinking I was late to the party.


Amy Jordheim: Nope, you're not late to the party. I said if anybody had a question I would answer it now though while we were waiting. Speaker 6: Oh, I missed that part. Amy Jordheim: I'm happy to answer it. Mary: Mary. Amy Jordheim: Hi Mary. Mary: Hello. Chad: This is Chad. Amy Jordheim: Hi Chad, how are you? Chad: Fine, good. Amy Jordheim: Great, okay everybody, so let's get started. I've heard lots of people come on, that's always nice. You're on a couple of different trips, so we've gone to a new format at IMR to have a monthly call like this every month, rather than having an individual call for every team. So we have more than one team on the line, but you are more than welcome to ask questions about your trip, as long as it pertains to clinic operations. Amy Jordheim: And then for the second hour, our provider guidelines and philosophies about how we treat patients and how the clinic functions from a provider perspective. First of all, I guess I'll introduce myself. My name's Amy Jordheim. I have been a volunteer at IMR since 2008. I've led about 45 teams into the field and a variety of different places of course, since we go lots of different places. My role at IMR, it still has to do with policy, but a lot of you will see me in the admin role. Amy Jordheim: I just retired after 40 years in pharmaceuticals, and took on the admin job at IMR. So you can expect if you're contacting the office, you can expect me to answer the phone, or to answer your email. I hope that I survive this moment, because there's a lot of work to do at IMR. Amy Jordheim: Anyway, we're gonna talk tonight about clinic operations. What we're hoping from this call is that you get a good idea of how a clinic operates, how a clinic functions,


what it looks like. The first thing that I'll tell you is that it looks different for every day and every location. In every place that we go. So there really is no way to describe what clinic will look like for you on your trip, on any given day. Amy Jordheim: We do have some constants though in clinic, and the first constant is that we strive for acute medical care, acute dental care, and health education. Those are three pretty equal pillars. Now, all of our trips of course are done through volunteers, and so we don't always have a dental component, but we certainly strive to have a dental component, and often use local dentists if we don't have a dentist from our volunteer roles, because dentistry is truly important. Amy Jordheim: By the same token, our health education program is equally as important as our medical program is, and our dental program is. So all three of those pillars are really equal and important, and, you're gonna hear about all three of them tonight. On any given day, our clinic is going to be set up in a location that could be a church or a school, or it could be under tarps, or it could be from a bus. I'm thinking that all the different places I've run clinic from could be from a bus, it could be partially from a bus; it could be under tarps that are tied to a bus; it could be within a very-structured clinic, and that health clinic could be all of two rooms, and each room could be four-by-six. Amy Jordheim: So you just never know what it's going to look like, and it's really the role of your team leader to come in and look around, in conjunction with your chief medical officer and some people on the team, to take a look around and to decide what's the best place to set this up. From that moment forward, you're busy. Amy Jordheim: I guess where I'll start is telling you about how we get everything to clinic. Once you understand how we get everything to clinic, then you'll understand how we set up each of our different departments in clinic. We'll walk through our departments as well. So we pack clinic in a modular fashion. When you receive the bag for an IMR trip, this might be in-country, you might be a subsidized flyer, and you might by physically bringing the bags. But when you open the bags, you will find a very modular system. So we pack, for example, we pack all of our IV departments, or our ICU department materials, into a single bag. And we pack all of our respiratory into a single bag, and we pack all of our provider equipment, or our triage equipment, or our registration materials, each into their own bags. Amy Jordheim: So clinic is set up in a very modular fashion, and each of you will be assigned a bag that you're gonna take care of each day. You might not work in that department, but it's your bag to get off the bus, your bag to open up in its designated spot and clinic, your bag to close at the end of the day and make sure that all of the supplies that are supposed to be in are


in it, and it's your responsibility to get that bag back on the bus. If you have respiratory for example, it's also your responsibility to charge the compressor every night so that we have a respiratory compressor in clinics, or a nebulizer compressor rather, in clinic. Amy Jordheim: So that's one of the many responsibilities that you're going to have on the IMR trip. As you see, as you open up each of these bags and you see what's in the bags, I think you'll get a good feeling for different ways that you can set this up to make it efficient for whatever area it is that you're gonna be setting it up in. There's gonna be four bags for pharmacy, and not surprisingly, those are adult RX medications, or adult prescriptive medication, adult over-the-counter medications, pediatric prescriptive medications, and pediatric over-the-counter medications. Amy Jordheim: In addition to that, there's also a pharmacy supply bag, so there will be many of you setting up pharmacy as clinic starts. Once all of the departments are set up, and everybody is in their correct place, then we will open clinic and you will begin to see the first patient. While all of that is happening, patients are being registered and being prepared to move through clinic in an orderly fashion. So your team leader and your chief medical officer are gonna walk through whatever space it is that you're in that day. Once they've decided where each of the departments are going to go, they will do a walk-through of clinic with you, so that you know where you're going to take your bag to set up. Amy Jordheim: Some of the constants in clinic are that every clinic has essentially the same department. Every clinic has a registration area, an area for community health education, an area for patient intake where we do vital signs, and where we triage patients to [inaudible 00:12:22] care and well care. An area for providers to work in, an ICU, a privacy room where you can do privacy exams, or if you need to speak with a patient in private, where you can do that as well. Amy Jordheim: Each clinic will have an area for respiratory, an area for wound care, an area for a small ICU where you might be doing IVs or oral re-hydration, or where a patient might be waiting to see their response to a blood pressure medication, as an example, but it's a place where an active patient might be waiting. There'll be a laboratory setup with basic laboratories, so that you're able to request labs for patients, and you're able to see the results in a very timely fashion, usually within 10 to 15 minutes. Amy Jordheim: So each of these areas in clinic will be designated by your team leader as the spot. Once you have that set up, and you've walked through clinic, it will become pretty clear to you what the clinic as a whole will look like. We also have signs that are sent in the clinic supply


bag, and this will help you know where things are. So some clinics, for example clinics in school, they will generally have a whole series of small rooms that are not out in the open. Amy Jordheim: So we'll put up a sign to designate the room that holds laboratory and wound care, and maybe the ICU; a sign that is designated for sick care or well care, or for both. We try to work very collaboratively, as you'll hear at IMR, and with that, we'll have sick care and well care together so that people can work collaboratively. You'll see many families in clinic, so you might have a family where you have two sick patients and seven well patients. So the sick providers and the well providers will work collaboratively in order to get that family seen, and keep the family together, so that everybody understands what's happening within the family. So if you're working in a place that has small rooms, you can expect to see signs to help you know where things are. I'm always grateful for the signs because I could never remember where things are, so it's very helpful to me when the signs go up. Amy Jordheim: So in each clinic, you're gonna have very similar departments. What the actual flow of patients through the clinic is will vary depending on what the setup is like. So in one clinic, you might have patients that are registered, and then receive community health education, and then do intake. In another clinic, you might have patient that are registered and get intake done, and community health education might be out in the crowd before the patients are every registered. Amy Jordheim: So it's very dependent on what the site looks like, how many patients there are, how large the team is, or how small the team is, what the extra piece of team is, what those orders are, and that really is what your team leader and chief medical officer will decide. Then they will have a morning briefing with you to help you understand what that flow is. It's important that you're at the morning briefing, so that you get the information directly and not from other people on the team, because then there's always the chance for things to go awry when you're playing that game of telephone, if any of you remember telephone. Amy Jordheim: So those are just some of the things that are gonna happen in the morning, but basically the first thing that happens is you will start to get patients registered. Registration is generally done through local help, so we hire people who are gonna come in and do registration for us in any given clinic. So as they are getting patients registered, you guys are all getting clinics set up. That does not just include the bags for clinic, that also includes, and if you guys could mute, it would be much easier for everybody else to hear. Just push that little mute button on your phone. Terrific, thank you so much. Amy Jordheim: So as patients are being registered, you guys are all setting up clinic, and that does not just mean the small bag for each of the areas of clinic. It also means setting up waiting


areas for patients, so moving benches. It might mean clearing out a room that's been used as a storeroom, that you're now going to use for something else in clinic. It might mean collecting tables and chairs from people's homes that's around the clinic. So it could have a lot of different meanings, depending on where you are. Amy Jordheim: I did a trip to Peru a few years ago. We left from Iquitos, Peru, which is the largest city in the world that doesn't have a road into it. You either have to fly in, or you have to come in by boat. We went 10 hours upriver in a fast boat, which is really far away from Iquitos. When we got to the little tiny village of [inaudible 00:17:26], the kids were building us tables and chairs for clinic, and the tables averaged about seven inches in their legs, and the chairs where much taller than that. You just never know what you're going to find. Amy Jordheim: What you will find, though, are people that want to help, people that want care, and people that need care, and that welcome you with open arms, many times with amazing ceremonies, amazing opening ceremonies, amazing closing ceremonies. Almost all of the people that we see have virtually no access to care. So when you go into a clinic, and you look around, and there really aren't any tables or chairs and you're sitting on cinder blocks, think to yourself that that's because there aren't any tables and chairs. Amy Jordheim: A lot of times, patients will carry their own chair to clinic, and will leave it for us and will come back at the end of the day and pick it up, and that's their only chair. Keep all of those things in mind when things maybe are a little less convenient than you would like them to be. We go to some very remote places, and it is what it is when you're in a very remote place. You are working within the confines of what the patients have, and what the patients are able to give you. It's important that you understand that. Amy Jordheim: So having talked a little bit for a couple of minutes about what clinic might look like, do you guys have any questions, anybody with a question about our modular setup, about how those decisions are made, all of those things? Speaker 9: I have a question when you said, just because I do triage in my job, so I'm somewhat familiar with it, I know it's gonna be different, but when you say well patients versus sick, what are you talking about when you say well? Is it people with minor things like they have a [inaudible 00:19:34] that needs to be sutured? Or is it they don't have a medical complaint and just want education? What do you mean by well and sick? Amy Jordheim: It can be all of those things, so well patients are patients who have had things chronically for a number of years, it doesn't affect them today, but they're in clinic and they would like to be seen. They get a general physical examination, and typically when they're


sitting in front of either our well care providers or our sick care providers, well care providers are nurses, sick care providers are advanced practice providers and physicians. Amy Jordheim: So when they're sitting in front of that person, they will often come up with a more acute complaint that they did not mention during the registration process when we get a chief complaint from them. So in our triage, we wanna find out how long patients have had their complaint, and whether they're acutely sick. They could have gerd, for example, they could have minor headaches, they might just have stomachaches, they could have just general pain, but they're pretty well. Amy Jordheim: So those patients see our well care providers, and then sick patients have temps, they have high blood pressure, they have all kinds of different things, but they're acutely ill, and they see acute care providers. Speaker 9: Okay. So the difference- Amy Jordheim: And many patients, many times our sick care providers will also see well patients, because we want to keep the flow moving through clinic. It's not unusual to have 300 or 400 patients in clinic during the day. Speaker 9: Okay. Amy Jordheim: So yep, I hope that answers your question. Other questions? Speaker 10: Hello, I kinda signed in late, I just wanna confirm this is for the trip for India, correct? Amy Jordheim: Well this is the Clinic Operations and Provider Guidelines Call, and there's a number of different teams on the line, including India. Speaker 10: Okay, great. Amy Jordheim: But it's not specific to India. Speaker 10: All right, thank you. Amy Jordheim: Sure. Other questions? Speaker 11: Amy-


Speaker 12: So, go ahead. Speaker 11: Thank you, sorry. Hi, this is Anna [inaudible 00:21:43] so my question is, how is it determined who is assigned to which area on any specific day. Does it have to do with the strongest skills, qualifications, or how is it rotated on a daily basis? Amy Jordheim: Depends on what your role is, so medical staff team members will rotate, do something different everyday, but licensed providers will generally work to their strengths, and your team leader will set a schedule, you'll know what schedule is by the day, and nurses for example fill a variety of roles. One day, you may do labs and wound care as well as, I'm sorry, labs and wound care as well as some well care when labs and wound care isn't busy. Amy Jordheim: Another day, you might triage patients, but for example we just had a triage nurse speak up, so if your strength is in triage and you love triage, you'll be able to do that; just talk with your team leader about that. We like people to rotate through a variety of roles, it's more interesting for them, it gives other people the opportunity to do more things. It can be very, we see a lot of patients everyday so it can be pretty overwhelming. Amy Jordheim: I imagine most of you don't see a few hundred people each day in your daily lives. So it can be pretty overwhelming if you love triage, to triage that many patients in a single day, and then do it again the next day and the next day. So we like people to move around, get experience in different areas. You also bring something to each role, experience to each role, and that helps us add to things. We change things in clinic pretty frequently as we get good ideas from all of you, and so there's that as well. So we like it when you guys move around. Speaker 11: Got it, thank you. Amy Jordheim: One thing I'll add to that is about community health education. So if you're a provider, if you're medical staff, if you would like to teach community health education, we are happy to give you a half-day off of your general duties to teach health education. It's really important, and all of our providers and well-care and sick care providers will also be teaching disease state health education at their station. Amy Jordheim: So that's just something that's a standard at IMR. I have a master's in public health, I write some CMEs, and just was beginning to write something about community health education and its role, and you know it's an extremely cost-effective way. It's much easier, much more cost-effective to prevent high blood pressure by changing diets, by increasing


physical activity, by decreasing alcohol consumption; all of of those factors that play into hypertension, but then it is to treat hypertension. Amy Jordheim: In sub-Saharan Africa for example, for anybody who's going to sub-Saharan Africa, fewer than 8% of patients that have known hypertension receive treatment for it. So if that's the case, then providing education about hypertension, about sodium intake, alcohol consumption, all of those things, makes a big difference to your patient. So teaching stretching stops patients from having general back pain, as opposed to providing some ibuprofen, which may or may not be taken appropriately, and which will run out. I don't care if you give them 5000 tablets of ibuprofen, it will run out. Teaching stretching is the most helpful thing you can do for a patient with back pain. Amy Jordheim: So health education is really important, so if you love to teach, we would love to have you take a little time off from your general licensed and boarded duties, so to speak, in order to provide some health education for our patients, both in our larger classes, and certainly at your stations. Also teaching other people on the team, many people on the team who have never seen scabies, if you have a great case of scabies, taking a couple of minutes to show scabies to other people on the team is another form of education that's really valuable for people, so that's my little plug for education at the moment. I'll take one more question and then I'll go on. Sarah Jacobs: Hi Amy. This is Sarah, hello? Amy Jordheim: Yes, go ahead. Sarah Jacobs: I had a question. I am going to be on the trip to India, so how will they, when we talk about health education and education, do we translators at each station? Amy Jordheim: Yes, you'll have translators, lots of translators. Sarah Jacobs: Okay, and for health education, do you have [inaudible 00:26:35] guidelines as to what topics you want to be taught at the different areas that we go to? Amy Jordheim: We provide all of the materials for health education, so there will be plenty of posters to use for teaching purposes, as well as small gifts for our classes. We hope that you will bring soap and nail files and things like that. You should've received an email about community health education as you being preparing for your trips. Some of you may not be far enough along in your weekly preparations for the trip, but generally you should've all received something, an email about community health education with attachments already. We hope


that you guys will supplement what IMR brings for health education gifts, but in general, we teach basic hygiene, sanitation, oral hygiene, and classes like that in our big classes. Amy Jordheim: Then at the stations, you'll have posters. You won't have a station at your poster, but you'll have a spot where there's posters put out. Those will be, you'll have things like vaginal infections, family planning, prevention of HIV, prevention of hypertension, prevention of diabetes, all of those kinds of big topics for chronic illness, which we don't really deal with in clinic, which we use education and referrals for. So you'll see a lot of those posters, but you should have received an email that has samples of our education material. Sarah Jacobs: We kind of joined in the last minute, we just registered recently, and I haven't received anything, so do you want me to call and request for that? Amy Jordheim: No. What's your name, and I'll send you out the materials that you've missed. Sarah Jacobs: Yes, Sarah Jacobs. Amy Jordheim: Okay. Sarah Jacobs: I have also have two other physicians on my team. Amy Jordheim: Yep, I know who they are. Sarah Jacobs: Okay. Amy Jordheim: So I'll get you some information out. Sarah Jacobs: Oh thank you. Nancy Austin: Do you know if the Philippines trip has received that email yet? I don't think I've seen one. Amy Jordheim: No, I don't offhand, but I'm happy to take a look and make sure, and I'll send it out to you too. What's your name? Nancy Austin: Nancy Austin.


Amy Jordheim: Okay, and if you have not received it yet, then I won't be sending it til it's time. Nancy Austin: Okay. Speaker 15: [crosstalk 00:29:10] either? Amy Jordheim: Well let's not do this on the call, all right? I'll take a look, and why don't I just send out that email again to all three teams that are on the line, how about that? Sarah Jacobs: Sounds good. Amy Jordheim: Okay. All right, so you've seen a little bit about what it looks like at the start of clinic, so now let's take a little walk through clinic. So in-clinic, the big areas that you're going to see are sick and well care providers, we haven't talked about pharmacy yet, sick and well care providers, an area for pharmacy, an area for dental, and an area for registration, intake, and community health education. Amy Jordheim: So you can sort of think about clinic in that setup, where you have four big departments, and then everything else is aligned with where it should be within those departments. So when you go into clinic, when a patient comes in to clinic, they're gonna have to move from department to department. On bigger teams, we'll have people to help them move, on smaller teams you might take a patient to their next station. Amy Jordheim: So for example, if you see a patient and they also need to go to dental, then you might walk them over to dental, you might ask your translator to take them to dental, or you might have a runner in clinic, depending on the size of the team who's gonna help them get to dental. It's important that you're aware that patients do need to move from one area to another, and that you take a look at their intake sheets. Every patient is gonna come into you with an intake sheet, and you should've received a copy of that in the email that was sent. If you wanna take a look at that after the call, you're more than welcome to do so. Amy Jordheim: So each patient will come in to you with half-page sheet of paper on both sides. The front side of that paper is mostly for our intake team. So it has lab results, it has blood pressure, temperature their weight; all of those basic intake things. The backside is for our providers, whether they're well care providers, or whether they're sick care providers. Amy Jordheim: When you look on the front side, you'll see an area for chief complaint, and if they have a dental request, then you will see that on the front side, and you'll know that your


patient needs to go to the dental. All right, so it will just be helpful to you in knowing what's gonna happen to your patient next, and to help you, or to help us, make sure that all of our patients get into the place where they're supposed to be. Amy Jordheim: Once your area, let's talk for just a minute about, we've talked a little bit about sick care providers and well care providers, but let's talk about our sick care pharmacy and our well care pharmacy. One of the things that we do to move patients through in a timely fashion, both for the patient and for us, is we set up a well care pharmacy. The well care pharmacy is pre-packed with common, over-the-counter medication, and they are set up at stations near our providers, whether they need well care providers or sick providers. Amy Jordheim: So you are able to just simply take the pre-packed medication that you're looking for, be it ibuprofen, or ranitidine, or tums, or an allergy med, Benadryl, whatever. Be it whatever it is that you're looking for, if it's a common over-the-counter medication, you'll find it in the pre-packs, and you will be able to give it to the patient, explain how to take it, explain any safety considerations for that medication, and move the patient forward. Amy Jordheim: If a patient needs a prescriptive medication, that goes to our sick care pharmacy. You can either send the patient to the pharmacy to pick up their medication, and then they will come back to you to have it explained, unless we have a registered pharmacist in the pharmacy, in which case they'll take care of that. Or you can send the prescription to pharmacy, and pharmacy will send it back to you and you can then provide it to the patient. Amy Jordheim: So that would include the less common antibiotics, suspensions that have to be mixed, any of those less common medications that you would not typically use routinely during the day. This has really helped our flow, our patient flow and our timeframe for patients in clinic, because there's not a line at pharmacy waiting to be seen. So you can expect to have, either at your station or on a central table, all of these common over-the-counter medications. With that comes the pre-packing part of it, so one of the things that the team will do at night is to pre-pack medication, they'll all be labeled with a card inside that gives the most basic instructions for how to take it, and what the name of that medication is, as well as the dose. Amy Jordheim: So they will be pre-packed into small bags with a card inside for your use during the next day's clinic. Like I said, this has really helped moves things along, so that's our sick care and our well care pharmacy. Pharmacy itself will typically be set up, so sick care pharmacy itself will typically be set up close to the exit for clinic. That's because if you're sending patients there, then we want them to get their medication and finish clinic, rather than coming back and walking back through clinic, which just impedes the flow of patients that are coming in.


Amy Jordheim: So if you're looking for the pharmacy, you can typically look at the exit; they're pretty easy to find anyway, and they're big to hide. Other than that, like I said, clinic's really gonna look differently everyday, but its function will be the same everyday. Once patients are triaged, their intake form will be marked as a sick patient or a well patient. If the team has runners, then they will look at each of the patients' intake forms and move them as they're opening. Don't sit if you have an opening for a patient, if you're ready for a patient, make sure that the runners know that you're ready for that patient. Wave your hand, stand up, walk over and get a patient if nobody is bringing you a patient. Amy Jordheim: What we wanna do is we want to keep patients moving through clinic, and it's just helpful to them to not be there for hours and hours. So if you're ready, raise your hand, let the runner know, get up and get a patient, ask your translator to get a patient. If we have specialists in clinic, which we frequently do, for example we might have a dermatologist in clinic, then rashes and other dermatology complaints will be directed to that physician, and many times they'll wait if we have an OBGYN in clinic. Amy Jordheim: If we have an internist in clinic, where we will try to have you not see the children. So there's some thought process that goes into this as well, and so that's really the role of the runner. So they will take a look at our intake form, the patient's intake form, and begin to make some decisions. Now in order for them to do that, it's very helpful if they know what you are. So you'll have a sign, we have signs for our specialists, and typically you'll have a sign either outside your room or on your table, so that our runners know what kind of physician you are. Amy Jordheim: Of course you physicians and advanced practice providers and well care, you can trade patients around as well. If somebody gives you a patient, and it's not a patient that you're used to working with, but you have another physician or another advanced practice provider on the team, you also can move patients from one place to another. This is also true for translators, so when you're working with your translator, you may have a male translator with a female complaint. That female complaint may be embarrassing to your male translators, offer to let your translator go to another provider and take one of the female translators to deal with that patient. So your goal really is to make things as comfortable as possible for patient in front of you, for your translator, and for you. Amy Jordheim: Sometimes a translator will be called to another provider, and you may be without a translator. Don't sit there wondering about a translator. Talk to your team leader, and we'll move another translator into place for you, or we'll find your original translator and do some swapping around so that everybody has a translator that they need, like, want, and


that's best for their patient load. Always go to your team leader for these things, that's why your team leader is there. To answer questions, to help makes things better, to get the things that you need. That goes down to something as small as water. We'll have plenty of bottled water in clinic. Make sure you know where the bottled water is. If you need a bottle of water, get it. If you don't know where bottled water is, ask your team leader and your team leader will get the water. Amy Jordheim: Try to do things--if guys could mute that would be really helpful--try to do the things that help you--if you guys could mute that would be really helpful. Try to do the things that help you see patients as efficiently as possible, and asking for the things you need when you need them. If you guys could mute that would be really helpful. Thank you so much. Really, that's essentially what clinic operations is all about. It's about keeping things moving, keeping patients moving. Amy Jordheim: So now you've seen patients all day long, we don't typically break clinic for lunch. Your team leader will come around and ask you to go to lunch. It's important that you do this, talking about keeping your translator comfortable, it's important that you go to lunch. You may not wanna stop for lunch, you may not normally take lunch, but everybody needs 20 minutes to recharge and regroup, and your translator needs to eat. Your translator needs a break, so when your team leader comes around and asks you to go to lunch, please go. They're asking you so that we don't close clinic. If you don't go, then your translator doesn't get to go, and eventually your translator will need to go and get something to eat. So please, break for lunch, take a break, let your translator go to the bathroom, make sure your translator has water. Take a break, because your translator needs a break, and you don't function very well without your translator. Amy Jordheim: So those are sort of the important things to think of when you're in clinic. It's not just when you would like to take a break, or the fact that you're not hungry, there are other people involved. Because if you've been asked to take a break, then someone else was not asked to take a break. It's a sort of flow, so it would be really helpful if you could do that and do those things when you're asked to do them. It's really important to your translators, your translators work so hard, they're speaking in two languages, sometimes three languages, sometimes four languages depending on the dialects and the tribes. Sometimes there's more than one translator involved. They have a really hard job and they are talking all the time, and thinking all the time, so give them the opportunity to recharge, regroup, get food, use the facilities, get a drink of water. Amy Jordheim: Having said all of that, any questions before we talk about how we close clinic?


Amy Jordheim: Good. Speaker 16: When does clinic actually open? Amy Jordheim: Clinic, we try to start clinic around 8:00. It depends on where you are locally, some places really don't get going until later in the mornings, depends on what the customs is in that area. We try to start clinic at 8:00, and we try to end clinic so that you're home by dark. In-between, we don't close, so we don't close for lunch, we don't close for breaks. Other questions about that, about anything along that line? It also depends on how far away clinic is, how long your ride is. So you might start clinic at 9:00 if you have a two-hour ride to clinic, or a two-and-a-half-hour ride to clinic, you might start clinic at 9:00 as an example. Speaker 16: Okay. Amy Jordheim: Always bring snacks for yourself to clinic, but having said that, you still have to break for lunch. You might be eating a bar, you might choose to eat a bar for lunch, but you still have to break so that your translator can get lunch. 99% of the time, your translator will not want a bar. They will want good, local food from wherever they live, and rightly so. Amy Jordheim: Okay, so closing clinic. At the close of clinic, one of the first things to understand is it's your team leader's job to not let patients stand in line that are not going to be seen. Let's say that the maximum capacity for your team is 250 patients. Your team leader will watch the line, will note how many people are being seen in a half hour, or 45 minutes, or whatever their pattern is, and they will close registration when they believe clinic to be at maximum capacity. In this way, patients will not wait and not be seen. Amy Jordheim: One of the problems with anything with patients waiting in line, if you've ever been to Haiti, you see it frequently, is patients believe that they will be disappointed because they have waiting many times and that truck has run out of blankets, not surprisingly. They've waited and not been seen in the medical clinic, they've waited and not received something that they were hoping to receive. So they get very nervous when they believe that there's a possibility that they will not be seen. So it's really our team leader's job to make sure that everybody that's waiting, that we're able to see everybody that's waiting. Amy Jordheim: At IMR, it's not a numbers game for how many patients we see per day, it's how many patients are we able to see well per day, and let's see that number. It's not about seeing as many people as we possibly can, it's about seeing as many patients as we can see well. That's important for you to understand, and it's also important to trust that your team


leader will not have patients waiting, that you all can see, and see well and see it effectively, and take good care of that patient. Amy Jordheim: I always tell people in these calls, that one of the most effective things you can do with your patient is to touch your patient. A hand on the shoulder means a lot to a patient who doesn't ever get care. A good exam means a lot to a patient who doesn't ever get an examination. Many times, they won't even mention that terrible wound because they're used to having a wound like that. So if you don't give them a decent examination, then you don't see that wound either. So watch the patient in front of you, it is about the patient in front of you. It is not about the patients waiting in line. Trust that your team leader will do the right thing. If you guys could mute, it really would be easier for everybody to hear. I'll give you guys a second to do that. Amy Jordheim: Whoever [inaudible 00:46:08] muted who's walking around out there, please mute, it's really quite noisy. Amy Jordheim: Okay, so it really is about you worrying about the patient that's in front of you, and taking really great care of that patient, and let your team leader worry about the patients outside of that. One of the things that we do, once we have stopped registration, if we still have patients coming then we will try to set up community health education outside, and they can at least be given community health education. While that's happening, it also gives our nurses a chance to triage the crowd outside, and make sure that even though we closed registration, we're not missing somebody who truly is acutely ill, and who does need to be seen. Amy Jordheim: So even though the registration might be stopped, that does not mean that no patient will be seen. It just means that we're gonna be more selective in who we see, and we wanna make sure that if somebody acutely ill comes to clinic, even though registration is closed, that we add that patient in, and maybe move that patient forward up the line, depending on what's wrong with them. It's important that we don't turn away acutely ill people, who may be the only doctor they see for the next six months. So that's just very important. Amy Jordheim: If you happen to be outside walking to lunch, and you see someone who's acutely sick, go ahead and bring them on in. They will need to be registered, but we can register them in place, register them at the station, and of course if they're truly acutely ill, we'll worry about the registration afterwards. Once clinic has closed, then it's simply a matter of working through all of the patients that are waiting, giving them good examinations, taking your time, seeing those patients well, and then when the last patient is done, we'll close clinic.


Amy Jordheim: So if you opened up your bag, if you're responsible for one of our department bags, then it is also your responsibility to go to that bag and close that bag up and make sure that everything is in it that needs to be in it. Jot a note for your team leader if you're low on something or if something is missing, so that we can either find it or try to source it. Once the bags are closed up, then we wanna put the clinic back in the order that we found it in. That clinic might be in someone's home, so we wanna make sure to try to put things back in the same order that we found it in. If it's a church, we might wanna put all of the benches back into their place. Sometimes we'll be told not to do that, that they'll do that for us, and that's great, just say thank you. Amy Jordheim: One of the most important things that we do during cleanup is to make sure that we haven't left any trash, particularly medical trash. Lab will have a sharps container, dental will have a sharps container; make sure that sharps are put into the sharps container immediately. We're a no-sharps place, we don't want any sharps hanging about. We also wanna make sure that our four-by-fours and two-by-twos, and just our general trash is all picked up before we leave the area. We either take the trash with us, or the host of that particular clinic burns the trash for us. Amy Jordheim: What we don't wanna do is just leave garbage bags completely unattended. The children will get into the garbage bags, they will scatter that waste around, and most of that waste is not stuff we really want children in. They'll do it remarkably quickly. They don't really have those boundaries that other children that you're more used to seeing have around trash. They're used to walking in trash, they're used to seeing trash, and so we wanna make sure that we're not leaving garbage bags that are not either being cared for by our host, and burned, or that we're going to take with us to dispose of properly. Amy Jordheim: That's just some of the guidelines of getting clinic closed. You'll find, after the first day, you'll find that the minute that you start closing up, and you still have 10 patients left, that everything you put on the bus will be needed. So it's really better to just wait for the last patient to be done, and then close it up and put it on the bus and get it on the bus. If you're responsible for one of our bags in the morning, if you opened the bag you're responsible for closing the bag and getting the bag on the bus. If you helped set up clinic that morning, you're responsible for making sure that that place is well set, and everybody else is really responsible for policing the grounds and make sure that we don't have any trash that's left behind, and things like that. You'll find that it can build up a remarkable amount of trash pretty quickly. Amy Jordheim: Each of the bags, so we talked about the bags earlier. Another thing that each of the departments has is garbage bags, and goggles, and gloves. Each unit of clinic truly is


self-contained, and you wanna keep them together. So there's going to be gloves in the respiratory bag, there's gonna be goggles and masks in the respiratory bag, there's gonna be garbage bags in the respiratory bag, in addition to the nebulizer compressor, nebulizers tubing, the associated medications used with those. So keep your bags together, and get them closed up nice and neat and you will not have to reorganize clinic at night, which is really, really great, especially for the people that are actually reorganizing all the bags. It's so helpful if you can close up clinic neatly, and sort of quietly, softly, and get them back to wherever it is you're staying in one piece, so that you don't have to spend an hour or two reorganizing all the bags, it's really helpful for that. Amy Jordheim: Once clinic is closed, you will frequently have a ceremony. Many times they will give, the patients that you see, not the patients that you see, but the organization that we're partnering with for that clinic, will give some sort of small gift to you to show their appreciation. It could be a little plaque, or it might be just their thanks, but you can expect to see that at the end of many clinics; not all clinics, but many clinics. So don't go too far afield, so that we can be pulled together as a team and show our appreciation back. They did a lot of work to bring us in there, and they did a lot of work during the day, and they really went above and beyond in order to make this happen for the patients in their area. So it's nice when our whole team can be together for that ceremony such as it is. Amy Jordheim: Also sometimes, you'll wanna thank your translators. Each team gets certificates for the translators, and sometimes you'll have translators that don't go on with you to the next location, so you'll wanna be there to say thank you to your translators with a certificate as well. Then you get back on the bus, you go back to where you're staying, you get to eat dinner, pre-pack medications, and do stats. We'll talk a little bit more about stats as we go along in our next portion, but the stats are also very important. Amy Jordheim: So IMR works with the Ministry of Health in almost every country that we go to. Many of most of our clinics are determined by the Ministry of Health, and we also provide statistics to the Ministry of Health after the trip is over. So when you are in the evening, when your team is done with dinner, one of the things that your team leader will ask you to do is to help with stats. That is simply collecting the information from the intake forms, and we'll capture a primary diagnosis, a secondary diagnosis, for each day, and then also run the demographics of age and sex. So that's sort of what the end of clinic looks like. You pack up your bags, you go back, you get to eat, and then there's a little more work to do. Then you get to go to sleep and get up in the morning and do it all over again. It's an amazing week, and it can be very fast-paced, but it can also be quite relaxed, and that just depends on what trip you're on.


Amy Jordheim: Our hosts are always local, so they'll answer any questions you have about where you are or where you're going to, and they'll talk a lot about the customs in that area. Feel free to ask questions, part of the reason they're there is to answer your questions and to help you feel comfortable in the environment that you're in. You just learn a tremendous amount from their perspective in this. Amy Jordheim: The last thing that I'm gonna touch on, Bill are you on the line yet? Bill? William Hughes: I am here. Amy Jordheim: You're always early Bill, it's amazing. Everybody, this is Dr. William Hughes. I'm gonna ask Bill to hold tight for two more minutes and I'm just gonna talk for a second a little bit more about community health education. William Hughes: Sounds good. Amy Jordheim: I'll throw in another pitch for community health education. It is among the most important things that we do. Most of our patients do a really good job at trying to take care of themselves, and a tiny little bit of knowledge, one key takeaway, can make a world of difference to them. So if you can make sure that your patients have received health education while they're in our clinic, and that their questions, that you're able to impart to them knowledge about how to care for a particular condition that they might have, or how to prevent a particular condition that has been bother them for some time, you have just done a world of service to them. Even though clinic might look crowded, take the time to give them that little bit of education. It's just so important to them and to their future, and to the future of their children. Amy Jordheim: Good public health research has shown that people in transition, pregnant women, women who have just given birth, people who have just retired from a job, or are moving their homes after a disaster, where things are different for them where they live, that those people are among the most receptive for health education. One of the reasons that IMR goes to the village, and does not work out of the hospital or the health center, is so that we see everyone; so that we see patients that are sick, and patients that are well. A big part of the reason for that is so that we can provide good health education. Amy Jordheim: If you have a patient that smokes, we have posters about smoking, and it's important that they understand what smoking does. They don't always understand what that cigarette is doing to their lungs, and that's true in America too very frequently. It's amazing


what Americans eat. So take the minute or two that it takes to talk a little bit about health education, and try to leave your patient with one very changeable idea. Amy Jordheim: So if you have a patient with headaches, for example, think about some of the root causes of headaches, of which dehydration is a major factor. If you have a patient complaining of headaches, ask them how much they drink and when they drink it, and is the water that they drink clean. The answer that you will get, if you wanna do a little poll among your patients, frequently the answer that you will get is they drink two ounces of water in the morning, and two ounces of water at night, and in-between they work in the fields in 90 degrees or 100-degree weather. You wonder why they might have a headache, and they didn't get anything to eat all day either. Amy Jordheim: So helping them understand that if they can purify water using [SODIS 00:58:55] which is one of the methods that we teach for purifying water. If they can keep a bottle of water with them and just drink a little more, it's not about drinking eight bottles of water a day. If your total water consumption is four to six ounces of water a day, it might be about drinking another four ounces and getting it to 10 ounces a day, and that'll make a big difference in your patients. So think about leaving them with one thing that's manageable for them to make a change of, and that's what's really important. Amy Jordheim: With that, I'm gonna turn it over to Dr. William Hughes. Dr. William Hughes is IMR's Medical Director, has been IMR's Medical Director for a long time. He has been on 10 trips, he's going to Rwanda this year, and we are so grateful both for his expertise and for his knowledge of field conditions, and also for the fact that he comes on time after time to talk about provider guidelines, and the philosophies that IMR provides care with, over and over to help all of you be more effective in the field. So with that, I'm gonna turn it over to Dr. Hughes. William Hughes: Thanks, Amy. Does anybody have any questions for Amy about the stuff she covered? Amy Jordheim: That's how I like it. William Hughes: That's how thorough you are. So this team is going where, Senegal? Amy Jordheim: Actually we have, oh my gosh, I don't even really know. We have India, do we have a Haiti team on the line. Speaker 18: Yes we have Haiti.


Amy Jordheim: Okay, so we have Haiti, India, and one more. Speaker 19: I'm going to the Himalayan expedition. Amy Jordheim: Oh yes, that would come up pretty soon. And we might have some [inaudible 01:00:53] Senegal on the line too. So it's all of the [inaudible 01:00:55] that are leaving within the next two to three, four weeks. William Hughes: Okay, and do we have IMR veterans on the line? Speaker 20: Yes. William Hughes: Good. Okay, well [inaudible 01:01:12] section of the presentation is supposed to be provider call. Although I'm talking to everybody, it's particularly aimed at the physicians, the PAs, the EMTs, nurses, nurse practitioners. I'm gonna talk fairly quickly about five different sections. One, we're gonna talk a little bit about team and team protocols, we're gonna talk about data, which Amy has already alluded to. We're gonna talk about the CMO and that person's roles, safety, and particularly safety while dealing with patients directly. Lastly, we'll talk about medications. The first thing I wanna talk about is team approach to the IMR trip that you've heard a lot about, what the team is going to do once they get on the ground. William Hughes: Remember that during the trip, prior to the trip, while you're in-transit going to the airport, on the airplanes, and during the clinics themselves, there will be discussions held about what to anticipate with the forthcoming trip. Also, if it's during the clinic, you're gonna talk about what you're seeing, particularly if there's any one big problem that's occurring in the location you're at. There can also be inter-clinic discussions amongst all the people providing care to the individuals that you're seeing. William Hughes: We work collegially, that means that we share individual expertise and experience to deal with any problems that crop up. A lot of times, that is not [inaudible 01:03:06] we don't have serious problems to deal with, but when we do, and if there's something you encounter that is difficult for you, or something you haven't seen, be sure to ask the other providers in the area who may have that expertise. If you have a local physician traveling with you, or assisting you at the clinic, of course you wanna lean on their expertise regarding certain conditions that are endemic to that area you're in. William Hughes: Remember also that the education you provide at your workspaces for the individual patient, to the patient's significant other or parents, should be integrated with what's being provided generally outside the provider area at the educational classes. So for instance, if


you encounter a problem of obvious dehydration, or what you think is contributing to the patient's complaint of headache or myalgia or arthralgias, and you can incorporate some of the education that's being put forth outside the provider area, and go ahead and reinforce that. It'll have double weight, and coming from you as a provider, as a physician, as a nurse, will mean even more to the patient. William Hughes: When talking about, let's talk about the CMO, chief medical officer's roles. There's basically three of them, and all the providers should understand what these roles are. The first thing is that if you encounter a patient that's particularly ill, or has some type of surgical problem, then that patient is often triaged outside clinics, outside hospitals, and it's the CMO's role to provide triaging that patient, in conjunction with the local contact and team leader, so that if you encounter something at your workstation that you know has to be triaged out, make sure the CMO is aware of that so that that can take place, and appropriate documentation can accompany the patient when they leave. William Hughes: The CMO's also responsible for team wellbeing, so if you start to feel ill, or if there's a member on the team that you find is starting to feel ill, make sure the CMO is aware of that, and that the person becoming ill is seen by a CMO. It's much better for the CMO to treat anybody who becomes ill that's a team member, as opposed to you as a ... a colleague doing that, and that's because we have to document what's going on and what we're doing for them, and make decisions about that particular team member. That's also done in conjunction with the team leader, who is also made aware of any problem that occur in this realm. William Hughes: Remember that there are problems that you will encounter during the clinic. Sometimes you'll see particular obvious surgical problems, masses, breast masses, abdominal masses, pelvic masses; things that are gonna require extended care, specialized care, surgical care. All these cases that you encounter should be discussed with the CMO so that appropriate steps can be taken, so that the patient receives the best care available. William Hughes: Next, let's talk about data. As you've been told, you will be getting an intake form, which will have the patient's name, age, weight, and hopefully vital signs and blood pressure and perhaps pulse. If they're having a respiratory complaint, we'll want O2 sats done on these people. There's usually oximeters that accompany the team, so that should also be on this form. Once you've assessed the patient, we're asking that you put down any pertinent physical findings, and that does not mean that you have to write down negative findings; just any significant positive findings, and come to a diagnosis. William Hughes: We'd like the primary diagnosis, and if there are accompanying diagnoses such as, let's say the patient comes in with a respiratory infection, but they're also hypertensive


or severely arthritic; you may put down the secondary or tertiary diagnosis also. This data is helpful, not only to the local health ministry where these stats can be provided, but also to IMR. If they're going to return to this particular locale in the future, it's nice to know what to anticipate in that location. So your data capture doesn't have to be extensive, but we like to see, nothing's worse than at the end of the day when you're looking up diagnoses, the tally, and you have a blank sheet in front of you. You have no clue of what was seen, and therefore it undermines the accuracy of the data. William Hughes: Next, let's talk about safety, particularly in handling sharps, in dealing with respiratory infections, in dealing with skin infections. Make sure that you use standard precautions against infection disease when dealing with your patients. So that, if you're dealing with wounds, if you're dealing with any kind of body secretions, of course you wanna be wearing gloves, you wanna be wearing goggles. There are masks available for respiratory diseases, or if you're doing any type of procedure or wound management. There are the few gowns that will be available if necessary, and there are some hats also available. William Hughes: Be careful when handling sharps, we're asking only that professionals handle the sharps, that is the nurses, the doctors, the PAs, the EMTs, so that we can minimize needle sticks. Now if you've been in the game long enough, you know that needle sticks occur; you may have suffered some even yourself. Even in the best of circumstances, it can happen. In the field, it's even a greater risk, especially if you're using a variety of dressings, for instance, and you happen to have used a sharp instrument, be that it's scissors or scalpel, or a needle for injection, you cannot let these things lay around. They will get lost within the four-by-fours, someone will get stuck. You know it's gonna happen, so as soon as you're done with the sharp, it goes into the sharps container, scissors go into the amethyst basin, or whatever you have nearby to collect the instruments, and be very careful about avoiding any type of sharp stick. William Hughes: The reason for that is because there is a needle stick protocol that you will find in your provider manual, and as you see on it, even though HIV testing can be done on the individual that you are working on, there are still anxieties that occur, and a protocol that has to be followed. The specifics of the protocol, I will let you read yourself, but you don't want to be, you don't wanna jeopardize yourself or anybody else. Be very careful when handing sharp instruments, protect yourself from infection by wearing appropriate safety equipment, which will be provided. William Hughes: I would advise every provider to bring their own box of gloves, so they know they have them, and that they fit. There are of course gloves provided in virtually every bag that IMR packs, but I would bring my own box of gloves if I were you, and make sure you have your own safety goggles too, even though those are also provided in the bags. As far as other


equipment, bring your own diagnostic equipment. That should mean a good LED flashlight, small, something you can use to check out wound; anything that you need for magnification, otoscope, ophthalmoscope if you choose, stethoscope of course. I bring my own BP cup. There are BP cups that are provided, that doesn't mean you can't bring your own. So bring whatever equipment you're comfortable using if you don't mind bringing it overseas, then I would bring it. William Hughes: The last thing I'm gonna talk about are medications. There is a list of medications in the provider manual from which IMR derives the med bags it packs. They do include usually first and second-generation antibiotics, antifungals, [inaudible 01:12:55], antiparasitics, specifically Ivermectin and Albendazole. There are also a large variety of antibiotic creams, ointments, antifungal creams, and some vaginal preps, so there's a variety of medications. The whole list is included in your packet, so familiarize yourself with that list. If you're not familiar with using any of those drugs, you may wanna do a little bit of homework and read up on those drugs. William Hughes: Good references that carry include, I think Amy will provide GIDEON's infectious disease for the location you're going to, and I would also bring along a Sanford Antibiotic Guide, just a handy item to carry. If you have a small manual of tropical diseases, I'd bring that also. There are some available that are excellent. William Hughes: As far as prescribing medication, and this is fairly important, the more I think about this, the more trips I make, the more I realize that you don't have to prescribe that much medication on these trips, thinking back. We have an inclination to treat everybody with something; in the U.S., that's fairly common. What we don't want to do is treat anybody unnecessarily, so be careful even with simple medications such as Tylenol, Ibuprofen, Aleve, these kinds of medications. William Hughes: We give medications out in small amounts, that is if you get Ibuprofen, you may only get 10 or 12 of them per patient. Antibiotics can be given sparingly, and only when necessary. A lot of these patients are antibiotic [inaudible 01:15:21], so you do not have to give maximum doses to them. You can give minimum doses, you can reduce the frequency of dosing and the duration of dosing, duration of the course of therapy for many of these [inaudible 01:15:37] infections. William Hughes: If you're not sure they have an infection, then I would err on the side of conservatism and not give them antibiotics. As you know, antibiotic resistance is a problem in the U.S., and in fact increasing in the western world, we'd just assume not spread that to the third-world if we can. Be sure that your medication dosing is focused, as simple as can be, and


as short as can be. We also recommend that any treatment regimen you give, that you give the first dose in-clinic, preferably at your workstation, so that you can make sure the patient is taking the medication appropriately, swallowing it appropriately. If it's a youngster that the parents or caregiver can administer that medication in an appropriate way, whether it's liquid or pill form. So it's very important that that first dose be witnessed. William Hughes: Also, don't give medications to children. These medications are prescribed not in safe-proof containers, but rather in plastic bags with the instructions written out inside, or on the bag, on the outside in marker. We don't wanna give these medications to children, so unless they appear to be a responsible teenager, you do not give these medications to children. Remember that there is an [crosstalk 01:17:26] component prescribing, so that you wanted to tell the patient why they're taking the medication, how they should take it, and for how long they should take it. Also, any potential side effects that are common with that medication, you should warn them ahead of time. William Hughes: Remember that you have amazing power at these stations. This is a Western doctor coming to their village, or to their small town, and so they're gonna be excited to see you. Some of them will be in awe of what you're doing and what you're saying. So what you say and what you give them has tremendous force and power, and we don't want to take that for granted, and we don't want to misuse that in anyway, so make sure that your prescribing is cautious and done with due diligence, as to the patient taking the medication, and understanding why they're taking the medication. William Hughes: A couple of comments about chronic illness, we of course don't medicate chronic illnesses such as diabetes or hypertension, because we simply can't carry these patients for any period of time with medication, but we can educate them as to the cause and effect of their condition, and point them in the direction of any local treatment or care that they might be able to get, and enforce to the patient the importance of followup, with regard to their high blood pressure or their diabetes, or their chronic lung disease. William Hughes: Anything you could do in the way of educating them regarding their condition, and what they need to do in the future, or what they can do, for instance with diet, with salt intake, with adequate fluid intake, this is all helpful. For hypertension, every now and then you will encounter a patient with extremely high blood pressure that you would consider in the danger range. Oftentimes, the CMO will have available some beta blocker effort, calcium channel blockers, that you could give as an attempt to stabilize this patient. But again, directly [inaudible 01:20:11] local care for their chronic condition if possible.


William Hughes: This is controversial, some people say it's not worth giving them any medication, but I know it's done on occasion simply because you're fearful of potentially immediate sequelae that could be devastating, such as stroke, heart attack, whatever. So if you have a means of stabilizing, you can do that, but you most provide for followup care as best you can, otherwise what you do has very little consequence. William Hughes: There are things you can do for hypertension, such as encourage adequate fluid intake, ingestion of potassium, minimization of salt intake, these types of things that you can do in the fields, and to help these patients, just to give them a little advice on some things they could do as they pursue further followup care for their condition. William Hughes: Okay, I think I've covered just about everything. Remember that the packaging that your medications come in are clear little plastic baggies, and are not childproof, so I caution you that even when you give out simple medication, seemingly benign medications like children-chewable vitamins, that these are given to responsible adults as opposed to the child, so they don't perceive it to be some type of candy or treat that they will take the whole bag full, not knowing the consequence. So be very mindful of that. Also, in patients that are elderly or dehydrated, I advise you to stay away from using NSAID agents on these people to avoid any type of real complication. William Hughes: If they have a lot of arthralgias or myalgias, you're safer to give them low-dose Tylenol than you are to give them NSAID agents. So many of these people in the villages that are doing agrarian work are clinically dehydrated, and I don't recommend putting an NSAID on top of that, so be careful even with things like ibuprofen; it is certainly not a benign medication, as you know. William Hughes: Okay, that's all I have. If you have any questions about any of this stuff regarding provider activity, go ahead and fire away. Speaker 21: I had a quick question. William Hughes: Sure. Speaker 21: I'm a nurse, and some of the medications, did you say that we will get a packet that has the list of some of the medications we may be administering that we can look over? William Hughes: That is correct. Speaker 21: Okay.


William Hughes: You should receive that, in one of the emails you should get a provider manual. In the back of the provider manual is the list of medications that IMR carries, okay? Speaker 21: Okay, so we [crosstalk 01:23:45] that. William Hughes: So you should get that. Amy Jordheim: You'll also receive the actual packing list for the team just prior to departure after we have completed packing the medications. Speaker 21: Okay. Amy Jordheim: And also, you received an email prior to this call, the well care guidelines, and that also talks about most of the common medications that we bring as well as syndromic management. Speaker 21: Okay, and that'll have things that we can reference as far as administering and education? William Hughes: No, it does not include the dosing. Speaker 21: Okay. William Hughes: That's why if you're not familiar with the medications, then you take a minute or two on each medication and look up the common dosing. These medications are pretty basic, and I'm talking about antibiotics mostly here; things like Amoxicillin, Keflex, Bactrim, Septra, Z-Pack, things like this. So they're not the most complex antibiotics in the world, and they're usually second-generation. Occasionally, they're third generation. Some Erythromycin for instance, some [inaudible 01:25:09] [DK 01:25:09]. The only injectable antibiotic that we carry is Cefadroxil, so you can read up on Cefadroxil and its common dosing. William Hughes: So if you know the common dosing, that's all you really need to know, and you can also take that down and shorten the course. For instance, if you're treating a sore throat, and you're not sure if it's strep or not, but you're suspicious, if you give penicillin, you could probably give it twice a day for five days and take care of the problem, rather than three or four times a day, or seven or 10 days. The point is that if these patients have not been treated recurrently with antibiotics, and they're gonna be [inaudible 01:25:58] there, the organism will be quite susceptible, and so will the patient.


William Hughes: So you can go lower dosing, shorter courses, less frequency. If you can get by with once or twice a day with any dosing of any medication, it's to your advantage, because compliance is not traceable in these people. It's poor in the U.S. when we do studies on it, so you can assume it's at least that bad in these villages, in third-world countries, so you can err on the conservative side, okay? If you're not sure they're infected, then don't give them an antibiotic, we don't need to create problems. Speaker 22: Okay, I had a question also Dr. Bill. William Hughes: Yes sure. Speaker 22: Does the provider manual include information about the conditions that are maybe endemic to the particular areas that we are going to? William Hughes: You should be getting an information packet tat includes specifically the country or the area you're going into. On part of that, there may be some references to diseases/conditions that you're going to encounter there. I would also recommend that you go on the CDC website, and look for the top 10 conditions in the country, or the location you're going to; that information is available. So you could pretty much, you'll get a good handle on what you're going to see, with a few exceptions. There are always exceptions. You'll get the common diagnoses. Most of these countries, the top five are gonna be cardiovascular disease, lower respiratory infections, communicable diseases like HIV, TB, you're gonna find some of those in most of these countries. But the CDC or the WHO will have these statistics for you, so just go on their website and Google it, and it will pop right up. Speaker 22: Okay, and also, the clinic supplies, do they include supplies to do [crosstalk 01:28:28] and drug injections and things like that? William Hughes: Yes, the wound care bag will have all kinds of gauze, wraps, rolls, you'll have scalpels, you'll have iodoform gauze, you'll have non-adherent dressings, adherent dressings, band-aids, aces, some splits, or split-making material; all this will be in the wound bag, but yes you will have that available. There should be basins, there should be iodine, and hopefully you'll have a clean water supply at your clinic, that everyone can tap if necessary, to do cleansing. William Hughes: Usually, we don't carry water for irrigation, it's just too bulky and heavy, so we use clean water that's available on the site, or something that we've made. I've used, sometimes we've just had these two-liter bottles, and I'll just use that for irrigation, but all the dry wound supplies will be provided.


Speaker 22: Okay. Speaker 23: I have two questions. So the first is [inaudible 01:29:48] hypothetical, extreme situation. Say a patient becomes pulseless, or haptenic or something, what is the extent of lifesaving measures we will be going to, to save this person? William Hughes: For respiratory arrest? Speaker 23: Yeah. William Hughes: Currently ABC, should have to do CPR on them. We have masks, we have airways, we have Ambu bags, and you've got your hands. We've got IV supplies for fluid. There should be some adrenaline available, there is cortisone available; that's what you would do. You would do your basic life support. Speaker 23: Okay, and then my second question is, earlier in the clinic operations, it was mentioned that we'll be discussing labs. What specifically, what labs are we gonna be testing? [inaudible 01:30:53] it's like [inaudible 01:30:54] test? William Hughes: The labs that usually accompany the team include multi-sticks for urine dipping. We do a lot of those. We bring malaria kits, which are simple indicator tests, testing for malaria. We have UCGs. Amy Jordheim: Pregnancy. William Hughes: We have HIV testing, but the HIV testing is saved not so much for the patients. I suppose in a rare instance you would use it on a patient, but it's used in the event of needle sticks so that you can test the patient from which the needle was drawn. Sometimes they have strep tests, but not every time. Those are basically the tests, there's not a lot, and of course oximetry, which is very important for our asthmatic patients, our chronic lungers out there; the pneumonia patients, how bad are they? William Hughes: Or somebody comes in blue and you're wondering, "Well geez, I wonder what their O2 is", so that's an important test that we do. Otherwise, those are really the only indicator tests we have. We're hoping to add more. Sometimes we have HemoCue, so that you could do hemoglobin on a patient, but that's largely it. More and more of these indicator tests are coming on the market, as IMR is able to get their hands on them, we may be including those


down the road, but right now those are the basic tests. HIV, malaria, urine UCGs, sometimes HemoCues, and oximetry. Amy Jordheim: If you do have a patient that you suspect to have TB or HIV, you do wanna refer them to the local health center or the local hospital. If we do the test for HIV and they're positive, they may not be able to get into their local system in order to receive free medications and counseling. We also don't have qualified HIV counselors on this team to work with these patients, so we refer them out for that reason, and that's why we don't do testing for them in-clinic. If they ask you for a test, refer them to their local health center, or to the local hospital. The tests are generally free in most of the countries that we go to, and there's really no reason why they shouldn't go to the local facility. Mostly it's because if we find them positive, they will not get into their local system and will not get care. Speaker 23: Thank you. Amy Jordheim: Absolutely. Speaker 24: Hi, I have a question. I'm a nurse practitioner student going on the Himalayas trip. I'm just wondering what my role will look like as a advanced practice student. Amy Jordheim: You'll work directly underneath the license and boarded provider, both advance practice providers and physician. You'll work within your scope as a student, so whatever you are allowed to do here in the United States, as a student at whatever point that you're at, then you will do that same role in the Himalayas. Speaker 24: Awesome, thank you. Amy Jordheim: Yeah, absolutely. Because you're working directly under a provider, it's really at their discretion whether they allow you to do more. Speaker 24: Yep, absolutely. Speaker 25: So I have a question about PPE isolation, things like that. If you do encounter patients that have, they talk about particular areas if you go to, there's the Zika virus, or some that have tuberculosis. Are there particular isolation measures we have take for those patients if we triage them with particular symptoms for that? William Hughes: If you have a patient that comes in with a history of TB, and are coming in because of the TB, those people need to be referred immediately out, rather than being kept in


the clinic. If the patient says, "I have a problem with, I have a wound on my leg but I also have TB", then you wanna do a couple things. You want the patient to wear a mask, you want their provider to understand what they have and why they're wearing the mask, and then of course you wanna protect yourself as a provider, to the extent you can with your own mask, et cetera. If they come in with a complaint of TB, then they have to be referred out, because there's nothing we can do specifically for them. We might give them a mask, but we're going to refer them as quickly as we can to their in-country, or their in-locale treatment center. Speaker 25: Okay, thank you. Amy Jordheim: Any other questions for Bill, primarily? Amy Jordheim: All right Bill, I think we're sprung. William Hughes: We're sprung, all right. Amy Jordheim: If you think of any questions, you're always welcome to email or call the office. The email is [email protected], and the office phone is 970-635-0110. I'm sure it's a phone number you think you will never forget again, and we're happy to take your questions and make sure that we get you answers William Hughes: That's correct, and if you have any specific questions for me, just contact IMR and they'll get me your phone number and I'll give you a call. Speaker 26: [inaudible 01:37:20] thank you. Amy Jordheim: Thank you everybody for coming on, we really appreciate it, and this will be sent out as a link to the teams. Speaker 28: Thank you. William Hughes: Are we all squared away Amy?

Sample Clinic Operations and Provider Call · Hi everybody, this is Amy, I'm with International...

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Transcript of Sample Clinic Operations and Provider Call · Hi everybody, this is Amy, I'm with International...