[This tape was duplicated from a 16mm film by Erickson Archival for the National Library of Medicine, September 2003. NLM call number HF4066]

On the Ganges River delta where cholera has remained a problem for centuries lies Dhaka.

[Ambulance driving along road]

This laboratory, established for research on the prevention and treatment of cholera, was placed in Dhaka where the disease occurs every year.

Patients with cholera are brought by ambulance from remote areas for treatment.

By the time a patient reaches the hospital, he may have lost 10 percent of his body weight as diarrhea and vomitus.

In a 50 kilogram man, this amounts to 5 liters.

He may be in shock, pulse-less in all extremities, and profoundly weak.

He cannot stand or even sit up.

It is entirely possible in cholera to be reduced to such a state in a few hours, but usually it takes from 12 to 18 hours.

His eyes are deeply sunken from fluid loss.

His fingers and toes are shriveled and cold.

His skin has lost its normal turgor.

His mouth and tongue may be dry unless he has just vomitted.

Patients are usually conscious and oriented, but senses may be dull.

In extreme states, the patient may be unconscious and close to death.

If the water and salt lost in the diarrhea of cholera are replaced swiftly and then a balance is maintained, survival is assured.

This same individual is now well.

With proper treatment, cholera patients recover quickly.

[The U.S. Department of Health, Education, and Welfare Public Health Service presents]

[a Public Health Service Audiovisual Facility production]

[Produced in cooperation with the Southeast Asia Treaty Organization Cholera Research Program of the National Institutes of Health]

[and the Agency for International Development]

[Cholera Today. Bedside Evaluation and Treatment]

When cholera strikes in areas where practitioners are not acquainted with modern treatment methods, many people lose their lives.

Case fatality rates in some effected populations may be more than 60 percent.

This unneccesary loss of life creates panic, seriously interferring with effective control measures.

Panic can be avoided by proper treatment because treatment can prevent deaths in even the most severe cases.

Although they represent only a small fraction of the number of infected persons, these severe cases are the greatest challenge to the physician.

When a cholera patient is brought to a treatment center, he should be weighed on arrival.

This information is used to judge the amount of fluid needed.

After weighing, while the patient is being placed on a cholera cot, the doctor can rapidly evaluate the patient.

The sunken eyes and cheeks indicate severe dehydration.

As does tenting of the skin.

The pulse can be felt quickly and easily.

Both volume and rate should be noted.

The blood pressure should be measured, if possible, by feeling the brachial pulse, as well as listening with a stethoscope.

On admission, the brachial blood pressure is often unmeasurable in severe cases.

The respiratory rate and depth are generally increased in cholera due to the accompanying metabolic acidosis.

Prompt restoration of lost fluids and salt is the primary goal in treating cholera.

Treatment must therefore begin immediately in patients with vascular collapse.

Placement of an 18 or 20 gauge needle in an appropriate vein is crucial for rapid infusion of fluid.

A second vein may have to be used to achieve adequate flow.

In small infants and children or even adults with difficult veins,

it is very important to be skilled in performaing vena punctures in a variety of sites.

Any superficial vein of the legs or arms may be used.

The external jugular vein may be the most accessible superficial vein in a young child and can be used in adults.

The use of scalp vein needles has greatly facilitated entering small veins and maintaining infusions in them

because they are easily manipulated and lie flat when taped down.

If such a vein is not immediately found, the femoral vein should be used to give fluid.

Cut-downs are not needed in cholera therapy.

The initial rate of infusion in a severely dehydrated adult, like this one, should be a minimum of 1 liter in 15 minutes.

Several liters are usually required for patients pulseless on admission.

Such patients need fluids equal to 10 percent of their bodyweight.

This 40 kilogram man required 4 liters.

When rehydration is complete, a patient should have a strong radial pulse and and normal blood pressure.

His eyes and cheeks are less sunken and his tongue is moist.

His breathing should be slow and regular and his skin should have its normal turgor.

After rehydration is complete, the rate of fluid therapy should match the measured rate of diarrhea.

All excreta and vomitus must be collected and measured.

The cholera cot channels all stool into a receptacle calibrated for easy monitoring.

Urine is collected separately.

A water-proof sheet with a sleeve attached assures quantative collection of the stool.

Continuing monitoring of intake and output, recorded on a simple bedside chart, is essential to the best care.

The characteristic rice water diarrhea of cholera is a straw colored watery fluid with a slightly fishy smell, not fecal in character.

The fluid lost in cholera is primarly this liquid stool.

Vomiting may contribute significantly during early rehydration.

A patient can purge up to 14 liters in a 8 hour period.

20 liters a day and 100 liters in a 5 to 7 day period.

This fluid contains sodium, potassium, bicarbonate, and chloride.

Fluids given in treatment should match the compostion of fluids lost.

This is the composition of the so-called "5-4-1" solution. [Chart: Composition of Intravenous Solution
[grams/l. NaCl 5. NaHCO3 4. KCl 1]]

An intravenous solution commonly used to treat cholera.

The salts are in the same proportions as in the cholera diarrhea of adults.

Children have slightly less sodium and more potassium in their diarrhea,

but patients of all ages can be treated with the same intravenous solution provided they are allowed oral water as desired.

Special electrolyte solutions are not nessecary.

Acetate or lactate can be substituted for bicarbonate in this solution.

Ringers lactate, or normal saline, can be given if extra potassium and bicarbonate are given by mouth.

Since children with cholera sometimes become hypoglycemic, the addtion of 2 percent glucose to their intervenous fluid is recommended.

After rehydration is complete, or if the blood pressure is normal on admission,

patients should be treated with oral instead of intravenous fluids.

Use of oral therapy can markedly reduce the amount of expensive intravenous fluids needed to treat cholera patients.

The oral solution used for cholera has less sodium and more potassium than the intravenous solution [Chart: Composition of Oral Solution]
[grams/l. NaCl 4.2. NaHCO3 4.0. KCl 1.8. Glucose 20.0

and is suitable for treating children as well as adults.

Glucose is necessary since the solution can only be absorbed in the presence of glucose.

If glycine is availabe, its addition further faciliates absorption.

8.25 grams can be added to each liter.

The ingredients of this solution are readily available in most areas.

As the solution is given by mouth, ordinary drinking water is used and the solution should not be autoclaved.

Oral maintenance therapy cuts intravenous needs of serverely ill patients by 80 percent.

In milder cases, oral therapy can completely replace intravenous therapy.

The solution can be administered by nurses or medical assistants on the orders of a physician.

Once a patient's blood pressure is normal, oral fuid can be given either by mouth or way of a nasogastric tube to match continued diarrheal losses.

After treatment has been started, a rectal swab should be taken.

Culture of this specimen will confirm the diagnosis and permit accurate public health reporting.

Once culture specimens have been collected, tetracycline or furazolidone should be given.

This will stop the diarrhea early, reducing the requirement for fluids and shortening hospitalization.

[Clipped soundtrack] villages, field treatment centers have been established.

At this center, in a tent, successful therapy has been given with only the simplest of equipment.

The only true essentials for satisfactory cholera treatment

are an individual skilled in judging and replacing fluid losses, the proper solutions, the tubing and needles with which

to give intravenous fluids, and tetracycline or furazolidone.

During epidemic situations, this irreducible minimum has been used with over 99 percent recovery.

To recapitulate the important points of therapy: the patient is quickly evaluated as he enters the treatment center.

Intravenous therapy of severely dehydrated patient is begun immedietly.

The wrinkled fingers known as "Washer Woman's Hands" and the loss of skin turgor signals severe dehydration.

The rapid deep breathing suggests metabolysis.

Absence of the radial pulse and unobtainable blood pressure indicate hypovolemic shock.

The heart sounds are faint and in severe cases almost inaudible.

Initial rehydration can be quickly accomplished through any large vein.

In small children and infants, a scalp vein needle in the external jugular vein is often succesful.

The femoral vein is used if necessary.

Oral fluid should be used to reduce the need for intravenous fluids.

It must always be remembered that proper regulation of the rate of intravenous and oral fluid replacement

is the key to survival of all cholera patients.

Careful bedside records of output are essential to the correct administration of replacement fluids.

Tetracycline or furazolodine is used to stop the diarrhea early.

Proper treatment is the most important part of any cholera control program.

With intravenous and oral fluid replacement therapy, patients recover and confidence is restored.

Person-to-person spread is not important in transmission.

Medical personnel and laboratory workers should not be fearful of their own safety. They almost never become ill with cholera.

With modern treatment methods, cholera need no longer be thought of as a dread disease.

[Technical advisors. Original Film--1966. Dr. Robert S. Gordon. Dr. W.B. Greenough, III. Dr. Norbert Hirschhorn]

[Revised Film--1971. Dr. John N. Lewis. Dr. Eugene J. Gangarosa. Dr. Abram S. Benenson. Dr. David R. Nalin]

[The end. M-1012. MCMLXXI]