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Theater Practice Guidelines

authorized by Survis Riscasi Ianshadi, DSM Surgeon-Subdirector for Wartime Practice
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THROUGH COMPASSION, SOLIDARITY

Control Class BLUE Sensitive. For codeword personnel only. Not for civilian access.
AuthorityWSODirectorate of Surgery & MedicineWPA "GARNET"
CodewordsDOVE GARNET-BLACK
NotesDD // DISCRETIONARY DISCLOSURE
Personnel may selectively disclose according to document-specific parameters.

Purpose of this document

This document is issued and controlled under the authority of the local office of the DSM/WPA, the Wartime Practice Authority of the Directorate of Surgery and Medicine. It is issued to medical personnel operating in a specific wartime theater to familiarize them with conditions on the ground, including biomedical idiosyncracies, logistical constraints, potential patient populations, and the local norms of care.

Information management

It is important to remember that like the rest of our science and technology, our medical knowledge and medicines themselves are more than just a boon to be dispensed at will: they are vital strategic assets capable of shaping the course of war, either in our favor or, potentially, against us. For this reason, all wartime practice is governed under the same strict constraints as other military activity.

However, this document has been endorsed for DISCRETIONARY DISCLOSURE, due to the harsh realities of emergent medical situations and the overriding importance of the DSM Core Mission: protecting the lives and comfort of the People at any cost. Practitioners on the ground are expected to use their best judgment in deciding when and where to disclose DD-endorsed intelligence.

An example of a situation where disclosure may be necessary or advisable ("disclosable circumstances"): lack of codeword-cleared medical personnel during an emergency surgery, forcing practitioners to rely on soldiers or even local talent.

An example of a situation where disclosure is inadvisable ("indisclosable circumstance"): A non-critical uastash civilian, allied or otherwise, is suffering from a condition, emergent or otherwise, that could be treated with proprietary Society medical science, but not without revealing actionable details of this science to the patient or local talent.

An example of a situation where a provider must take action for the preservation of strategic assets ("asset sequestration"): A uastash civilian has been treated in a way that required disclosure of proprietary science to local talent or to the civilian herself. A provider would be justified in issuing a Medical Order restricting the movement and/or communication of said civilian until such time as the threat posed by asset communication to external sources is negligible. Alternately, amnestic drugs such as sylazepam or fluorohexacryne (or anaesthetics such as ketamine or dicyclofol) may be used to block long-term memory of patients undergoing indisclosable care.

Which foreign patients are determined "critical" is left to the discretion of the provider. These decisions will be evaluated on a case-by-case basis. While humanitarian sentiments are both admirable and appropriate, providers are expected to retain their sense of priority, and be cognizant of the lives their actions may indirectly affect or destroy. The survival of the People is our ultimate, insurpassable priority.

Theater GARNET-BLACK

Patient populations

Due to idiosyncratic cultural values, the Khmai consider expression or admission of pain to be an act of moral or spiritual weakness, and will habitually attempt to deceive practitioners who ask them to rate their pain levels. For this reason, analgesics and anaesthesia should be used liberally in Khmai patients. Cultural sensitivity training for this population emphasizes the recognition of outward signs of pain, and appropriate ways to introduce and offer analgesia that will improve rates of patient consent and compliance. Outright discussion of pain ("this drug will make your broken bone hurt less") should be avoided in favor of more sensitive approaches ("this drug might make you a little more comfortable") to keep the patient from feeling judged.

Former "junkies" (opium addicts) or those who have been affected by addiction, while they may honestly report pain levels, are extremely unlikely to accept any drug recognizable to them as an exorphine agent. Fentadone-dibutaxin ("co-fentadex") should therefore be used exclusively in this population where viable, and providers should make the effort to introduce analgesics to the patient in the least threatening manner possible, avoiding comparisons to opium, and underlining the antiaddictive properties of dibutaxin. Highly-selective NMDA antagonists such as levo-fluoroxine may be used at sub-surgical doses as a first-line treatment for pain in those patients who nevertheless reject euphoriant analgesics outright, though for obvious reasons extreme care must be used in the chronic administration of these drugs. Ketamine is not considered a suitable drug for this purpose in non-emergent circumstances.

Use of exorphine agents

Endorphin-mimetic drugs (typified by fentadone) are endemic to Garnet in the form of "opium," a drug prevalent throughout Imperial space. Unlike fentadone, opium is not used in a medical setting in the Imperial context — its synthesis, possession, and consumption are highly illegal, punishable by death or internment. Despite this, opium is prevalent worldwide, and is used widely by vulnerable individuals such as the homeless population.

Active in the milligram range, opium is a much, much weaker drug than fentadone, which is active in the microgram range. Opium is thus also less suited to interstellar transportation. Chemically it appears to be a mix of inactive chemicals with several close analogues of alpha-endorphin, binding to the same receptors with much the same efficacy. However, opium does not have the NMDA antagonism of fentadone, and is not administered with selective kappa agonists like dibutaxin or delta antagonists like naltrindole, both of which are present in the majority of domestic fentadone formulations. Opium is thus less efficacious as an analgesic and known to precipitate intense physical dependency, even from a course of use no greater than one season.

Due to these properties and this culture of use, opium-like drugs (or "opioids") are of great interest to the Imperial population, a fact which must inform use, distribution, and dispensation of exorphine agents by the Associated Powers. Particular care must be taken in regard to fentadone, whose calmative and euphoriant properties are much more intense than those of opium. Civilian attacks on Society convoys undertaken in attempt to seize fentadone supplies for black-market sale have been reported both on Garnet and on other occupied worlds, and fentadone overdoses are extremely common in the opium-using population due to the difficulty in measuring microgram doses.

In an effort to both discourage criminal attacks on Society personnel and ensure the wellbeing of vulnerable civilians, the Associated Powers have adopted the following policy. Opium production and use has been legalized in all Occupied Territories, pursuant to regulation by the tripartite Inter-Pact Opium Commission. Opium and limited amounts of fentadone may be rationed to the civilian population, though care should be taken not to introduce the habit of opium use to those not already accustomed to it. Dispensation could be limited by methods such as low-profile distribution, direct outreach to addicts, checking the bodies of alleged addicts for "track marks" (see Exhibit A) or collapsed veins, examinations for the classic signs of withdrawal, and/or interviews to judge alleged addicts' familiarity with the drug, the street culture surrounding it, and common "junkie jargon" used by the addict community. Proportionate doses of dibutaxin/naltrindole ("dibutadol") must be added to all exorphine-containing products to minimize addictive liability. (The DSM has ruled the formulae for the total synthesis of dibutaxin and antifent of negligible strategic significance and therefore disclosable assets. Accordingly, they have been released to allied powers throughout the Imperial theater. Naltrindole remains a proprietary Society agent, due to the sensitive nature of the technologies required for its manufacture.)

While studies of opium are ongoing, the WPA has made the provisional determination that it is safe for limited oral use in Society citizens when fentadone or other safe, reliable synthetics are not available. Opium is not however cleared for intravenous use unless produced, purified, and guaranteed by a WPA-cleared facility. "Black market" opium vials are often highly contaminated and of unclear potency; thus, intravenous use may lead to abscesses, overdoses, and in the long term, deep-vein thrombosis. As oral opium is only a tenth the potency of intravenous opium, overdose is much less of a risk.

Antibiotic resistance

An alarming trend recognized worldwide is the presence of pathogens resistant to syrocillin and its derivatives. These pathogens, particularly that known to the native population as "moon-fever," have already caused deaths among the People, as well as allied populations. For this reason, the DSM/WPA has taken the highly unusual step of authorizing a second-line antibiotic for distribution to field medics. Providers thus will need to exercise judgment in the selection of antibiotics to administer in the case of suspected infection. While syrocillin remains the first-line treatment of choice, it is recognized that the danger of deaths due to syrocillin-resistant pathogens ("SRPs") justifies the use of cedromycin against any infection that cannot be proven to be syrocillin-vulnerable. The extreme lethality of local pathogens renders microbial infection an intrinsically emergent circumstance in all cases.

Particularly, if providers even suspect a case of "Arctic Wasting Syndrome" (of which wild pien şai populations in the region are known to be asymptomatic carriers, and which is transmissible through saliva), treatment with cedromycin is authorized in the field. Affected patients should be transported to a secure medical facility for quarantine and adjuvant treatment with thirdlines. The emergence of cedromycin-resistant AWS is considered a major regional threat due to the robust arctic pien şai population.

It is not known how so many bacteria on an alien world acquired resistance to a proprietary Society antibiotic prior to our arrival. The working hypothesis of the WPA is that some past civilization, possibly the Untúhpana Nnáhaku itself, independently developed and overused syrocillin or an antibiotic with a similar mechanism of action. Providers are advised to consider this an object lesson in the extreme danger posed by antibiotic overuse.

Due to the extreme lethality of local microbial pathogens, the DSM determined it prudent to authorize the delivery of a small stockpile of diclozacin, currently the only known antibiotic designated as a fourthline, to the Occupational Capital. This stockpile, assigned an asset category normally reserved for strategic nuclear weapons, is not currently authorized for use in any circumstances, and is maintained only as a safeguard against the emergence of an interstellar plague. Providers are advised that orbital bombardment of civilian settlements will be used preferentially to diclozacin dispersal.