Monday, 13 August 2012
THE ROLE OF SURGERY IN DISASTER MANAGEMENT AND DISASTER PLAN
INTRODUCTION Indonesia is geographically located in areas prone to natural disasters, technological failures and human-induced. This is exacerbated by the crisis in the form of multidimensional complex emergencies, including the social nuances of racial unrest, transportation and industrial accidents and outbreaks of work due to outbreaks of infectious diseases. Even the recent terrorist attacks in the form of bombs are also more intense. This situation always raises a broad impact on the health problems of life and livelihood of human disorders, deaths and illness, environmental damage and health facilities etc.. This leads to health as the spearhead of the disaster response, where the first has always found the victim dead and many sick. Hence the need for knowledge of disaster management so well that in any event of a disaster can be overcome by good without having to take more casualties. Disasters can occur unexpectedly at any time and in various forms such as the Tsunami, Earthquake, Fire, explosion, toxic gas leaks or nuclear radiation and other natural disasters that followed. Natural disasters can cause casualties and huge losses if it can not be controlled with a fast and organized. Large-scale disasters also require an integrated management involving a variety of elements and a great resource, planning and proper management and sustainable education. The most fundamental question is whether we have to deal with every possibility of the worst that will happen due to the effect or impact caused by a disaster? REVIEW REFERENCES Disaster (disaster) is a serious disruption of the functioning of a community, causing widespread loss of human life in terms of material, economic or environmental and are beyond the ability of communities to cope with their own resources. (ISDR, 2004) Disaster is a combination of threats (Hazard) and vulnerability (Vulnerability). Phenomenon, namely the threat, danger or risks, both natural and unnatural that it can (but not necessarily lead to disasters such as floods, landslides, drought, disease, armed conflict etc.. While the vulnerability is a state within a community that makes them susceptible to the harmful effects from threats such as physical vulnerability, social, and psychological / behavior. Handling or Disaster Management (Disaster Management) Disasters are iterative activities undertaken to control and state disaster daruat, while providing a framework to help masyarakt in a state of high risk for DAPT avoid or recover from disasters. The purpose of disaster management are: A. Reduce or avoid physical harm, economic and life experienced by individuals, masyarakt state. 2. Reduce the suffering of disaster victims. 3. Speed up recovery. 4. Perlindunagan give to refugees or displaced people when life is threatened. For purposes of the above required number of stages in an attempt to deal with a disaster A. Emergency Management; the effort to save lives and protect property and handle the problems of damage and other impacts of a disaster. While the emergency conditions caused by extraordinary events that are beyond the ability of people to face him with the resources or capacity exist so it can not meet basic needs and the drastic decline in the quality of life, health or security threats directly to many people in a kominitas or location. 2. Recovery (recovery) is a process through which that basic needs are met. Recovery process consists of: • Rehabilitation: direct repairs needed that are temporary or short term. • Reconstruction: permanent repairs 3. Prevention (prevension); efforts to eliminate or reduce the possibility of a threat. For example: the creation of dams to prevent flooding, biopori, planting crops on the hillside to avoid flooding and so on. But be aware that prevention can not be 100% effective against most disasters. 4. Mitigation (mitigation); the efforts made to reduce the harm of a threat. For example: the realignment of rural land that floods do not cause large losses. 5. Preparedness (preparedness); the preparation of a plan to act when there is (or is likely to happen) disaster. Planning consists of estimates of the needs in emergencies danidentifikasi on existing resources to meet those needs. This planning can reduce the adverse impact of a threat. Some of the principles of preparedness, among others • Development of information networks and systems of Early Warning Systems Network (Early Warning System / EWS) • Planning and preparation for evacuation of the stock of basic needs (food supplies, medicines, etc.) • Improvements to infrastructure can be used in emergencies, such as communication facilities, roads, vehicles, buildings as shelters etc.. Disaster Medicine Disaster health (health disaster) is penurunanstatus overall public health is not able to overcome. Disaster medicine called humanitarianmedicine which is a branch of medical science in the sense of immediate medical assistance (emergency) and health in disaster management activities regardless of political ideology and statehood. According to WHO reports, the number of deaths from the disaster probabilities of each decade from 1951 to 2000 always decreases although the number of disasters and victims has increased. Similarly, the probability of death due to the data of the earthquake from 1960 to 2001 participated decreased. The decrease was probably caused by the development of disaster medicine in the form of increased activity of prevention, mitigation and coordination system, changes in natural variation, or a combination of management and coordination system with the change of natural variation, but can also be due to inadequate reporting of data. The basic principles of disaster management can be done by eliminating the disaster (preventive), eliminating or reducing the damage inflicted on the population and environment bencanatersebut (therapy), or a combination of preventive and therapeutic. For this, the team must understand the pathophysiology or mechanism of the disaster from the beginning of a hazard to the disaster as shown in Figure 1. They should be able mengembangkanketerampilan and disaster medical knowledge in order to achieve proper control or management, effective and efficient. Therefore, the purpose of management after a disaster is the return on the health status of victims as they are for or against the impact of disasters on the health of the victim or prevent the disaster not occurred. Disaster management strategy must be owned by the team are: (1) modify the hazard to prevent disasters or reduce risk factors resulting in the reduction of negative effects on society and the environment, (2) reduce the vulnerability (vulnerability) and the vulnerability of society and the environment for the future; and (3) improve disaster preparedness in order to damage minimal.1, 7 -, 9 It is concluded that the team should be able to do the prevention, mitigation, eliminating the risk factors to prevent disaster or to prepare the public and the environment to prevent or reduce damage to the victim not cause disaster. Therapy Preparation means to prepare community strategies, teams and hospitals to manage post-disaster victims, the ability to mitigate against the victim as soon as possible, the ability to reduce pain and promote healing and rehabilitation. Preparation also includes warning systems, evacuation and relocation of a safe place, food preparation, medicine, clean water, financing, tents for victims, personnel, and simulation exercises by the team, the community and hospitals. Sample preparation areas Mount Merapi in Yogyakarta to evacuate the population and determine the area / relocation in the event of increased activity of Merapi with simulation training at the Hospital Sardjito.1, 7.10 Eliminating risk factors is to free the possibility of negative effects, because of the team should be able to understand how to eliminate risk factors. Risk factors are called risk maker, like a pile of snow at the top of the mountain may be flooding and mudslides when the snow is melting. Several observational studies show changes in behavior or animals in the area of Mt Merapi is a sign or warning of an increase in volcanic activity. The team should be able to eliminate the risk factors established by personal behavior, lifestyle, culture, environmental factors, characteristics of the descendants of people who related to health. For example, bus accidents occur due to the drivers often consume excessive alcohol, because it is necessary to check levels of alcohol in the driver's body on a regular basis so that bus accident can be prevented or reduced. The team needs to determine the category of victims of the disaster management as follows: (a) minor injuries (walkingwounded), (b) serious injuries (severe Wounded) or the victim was pinned under heavy objects or buildings (burieddeeply under rubble), and (c) the victim died. As a triage team should be able to select victims based on the total score. The highest score should be given help and then transferred to a hospital after the victim kegawatannya resolved. Action Surgery / Medicine are carried out in accordance with what we learned from: A. ATLS è A, B, C, D, E & Traige 2. BSS è Sew sewing, debridement and external fixation 3. Damage Control Surgery è DSTC (Stop & Stop Bleeding Contamination), Triad of Death (hypothermia, coagulopathy, and acidosis is never an uncontrolled) & Compartment Syndrome. 4. Peri Operative Critical Care è Total Care Handling a wide range of disaster medicine: a. Lightly Wounded Generally, minor injuries caused by collision or a mild crush of bodies. Victim left the affected areas to safer areas or family and community / volunteer took him to the health services have been provided by the team or the nearest hospital. Lesions are mostly kontusi, lacerations, fractures and dislocations, strains, sprains, minor head injury, compartment syndrome and the presence of foreign bodies in wounds such as wood, sand or broken glass. The team should be able to do the treatment on the victim such as wound care, antibiotics, anti-tetanus or analgesics, immobilization and resuscitation and treatment of comorbid victims themselves. b. Trauma victims or oppressed by the weight of objects or buildings Serious injuries or victims trapped by heavy objects or buildings are in need of immediate resuscitation aid. That is, the team must have the skills to perform resuscitation as life-savingbersamaan with the release of the victims of the crush of heavy objects and bring to a service that has been prepared. Special to the release of the victims who are isolated in the ruins of the earthquake should always be coupled with resuscitation procedures. This procedure has several difficulties such as the position of the victim and the very limited room for maneuver oxygenation. Therefore, the team must have the skills and specialized equipment to free him. Another issue to consider when building is wedged stability of the building, as subject to collapse again. Bantul is the area with the traditional architecture of the system consists of bamboo and wood, some without a reinforced concrete wall. Most of the victims of the fall of materials or the ground floor walls of the house bare soil resulting in inhalation of dust on the victim. The victim's family or neighbors who do not automatically release the victim injured by improvised means and without the knowledge of disaster medicine. The victim was immediately taken to a safer place or to the health care that has been prepared by a team without thinking of resuscitation. As a triage team to send the victim to a hospital that does not fit with or without the knowledge of life saving facilities. Some communities also took the victim to the hospital by using a private vehicle transportation, truck or bus without thinking first aid. There are also issues that resulted in the victim late Lifesaving assistance, such as the issue of tsunami earthquakes in Yogyakarta, so people are not hurt trying to leave the victim to a safer place and the victim died without help. c. Airway and Ventilation Problems The team must immediately secure the airway (airway) and ventilation to the need for oxygen and rehydration in order to avoid complications of hydration. According to the disaster in Kobe in 1995 and the earthquake in Turkey in 1999 found 12.9% -25% of victims with trauma that cause piston pernapasan.Di Yogyakarta in 2006 found 63 victims of trauma piston so that the concentration of oxygen in tissues is reduced. The team should be able to identify the presence of toxic gases, chemical gases, or dust or inhalation of carbon monoxide in volcanic earthquake, tectonic earthquake, buried in the ground or trapped indoors. All these problems can cause damage to lung function or gas exchange impairment. As a result the victim menjadihipoksia, hiperkrabia, respiratory acidosis, shock, and decreased kesadaran.Korban should be given an oxygen mask or intubation and measured concentrations in peripheral oxygen saturation by oximeter. Generally the victim face down position, the victim is limited space for intubation, and usually the victim is unconscious (coma) or semi-conscious team must have the skills and tools specific to the situation. Many drug induction intubation depends on blood pressure and suffered head trauma victims. Teams often use thiopental, etomidate, ketamine and succinylcholine. These drugs should be considered the advantages and disadvantages to the consumption of oxygen in the brain, heart and respiration activity and vascular conditions of the victim. The use of succinylcholine may result in paralysis, therefore the use of these drugs have to be careful. d. Crush Syndrome The team must predict the crush syndrome in victims of the compression in the long term by a heavy object. More than 40% of disaster victims who suffered crush syndrome alive by a falling heavy object. Report of the earthquake in San Francisco, Armenia (1988), Iran (1990), in the Great Hanshin Awaji earthquake, Japan (1995), and Marmara, Turkey (1999) found that there is a crush syndrome in need of dialysis and died There are also reports disastertidak found abnormalities such as an earthquake in Mexico City in 1985 and in the Philippines in 1990.Tim should be able to diagnose the crush syndrome. Increased muscle strain that will affect the permeability sarkolema and the metabolism of extracellular fluid into the sarkolema which would cause cellular swelling and impaired function that ends the death of muscle cells. Swelling of the muscle will cause compartment syndrome. Intracellular death and muscle into the circulation. The end of this process, the victim will experience hyperkalemia, hypocalcemia, hyperphosphatemia, metabolic acidosis, and myoglobinemia ataumyoglobinuria. The victim will die suddenly (cardiacarrest) or acute renal failure (acute renal failure). Victims of the earthquake or a war that uses a powerful explosive devices can cause crush syndrome, severe damage to soft tissue and muscle, hypovolemic shock, and infection. Therefore, the goal is to improve the management of victims crushsyndrome hydration and urine output (diuresis) that the metabolism of toxic and myoglobin do not cause acute renal failure by hemodialysis. Rehydration treatment is to give Ringer fluid with a dose of 20 ml / kg / hour for children and adults, or 10 ml / kg hour for the elderly or 1-1.5 L in the first hour combined with the administration at a dose of 44 meg bikarbonas / per liter and the maximum 300 ml for the victims who suffered anuri. Mannitol is sometimes needed when the urine output (urine output) <200 ml / hour. Provision of 20% mannitol in combination with Furosemide. When the urine starts out, the infusion should be reduced. The team should monitor the urine out of therapy, blood pressure, and check the peripheral oxygen concentration, respiration and chest auscultation. The team should be able to identify the causes of such crushsymdrome massive muscle damage due to trauma, delayed until at referral hospitals, and inadequate resuscitation during transport and at the referral hospital as well as team personnel skills are very minimal. e. Head Trauma Head trauma due to impact or trapped victims bangunanharus predictable though not visible in the crush room will experience hypoxia, hypertension, and dehydration. Clinical signs of head trauma is impairment of consciousness, signs of lateralization, and convulsions. When there is trauma to the head of the team always predicted the existence of spinal trauma to the cervical area, especially not proved in the next examination. The goal of treatment is to prevent head trauma occurs agartidak hypoxemia and lower blood pressure. Prehospital treatment of severe head trauma must achieve an average blood pressure 90-110 mmHg with saturation (SaO2 = 100%). Oppressed victims of a heavy object to the provision of oxygen even if I have to do intubation with hyperventilation procedure with the use of narcotic sedation. If there are symptoms of a seizure, the victim must be given 10 mg diazepam or phenobarbital intravenas more than 10 mg / kg and followed by 1mg/kg / h. Lowering blood pressure is given 25-50 g intravenous Mannitol and Furosemide 20-40 mg every 4 hours. Antikovulsi drug should not be given to victims who are still trapped under buildings or heavy objects. f. Hypothermia Hypothermia victims need to be estimated on the still under the crush of heavy objects or other disaster, because it is difficult even corrected high-temperature environments. Therefore, open the victim's clothing to perform the initial inspection is only done when there are indications of life-saving. Victims should be covered to prevent hypothermia. Hypothermia has the advantage of the victim as the victim increases the body's defense but also have adverse effects on health. Temperature 32o-33o C can reduce neuronal damage after head trauma, but have a negative effect on the metabolism and hemostatic function. Increased oxygen demand, platelet activation and blood clotting action of the enzyme is inhibited. Can be concluded hypothermia is an independent risk factor early death or due to the crush of disaster victims. The use of heating, wrap the victim, and the heated fluid infusion could not prevent the decrease in temperature of the victim. g. Burns and Inhalation of Dust Burns, inhalation of dust, and damage eyesight or the oppressed victims of the disaster caused by explosion of gas and electricity should be a concern. The team should be able to perform debridement of burns and then closes the wound with sterile gauze, antibiotics and tetanus prophylaxis as tetanus toxoid 0.5 ml and life-saving. h. Victim Dead Death of the victim and also the cause of death Meru feed document very beharga for analysis. Generally, the cause of prehospital death can not be determined because the team is only focused on morbidity. According to Coupland 20-24% of sudden death can be prevented at the disaster site with the proper management and directed. The team and the hospital's medical staff must be able to prepare their transport into the space provided in order to reduce the buildup in the disaster site. Summary The team should be able to understand the disaster that patofisologi accurate casualty management. They also had to respond and prepared to perform resuscitation, prophylactic immunization and medical treatment of victims. They also must be able to monitor the required energy, hydration, and clinical signs of stress that would arise on the team. The team should be able to classify the victims were slightly injured. They come to the services provided. ; Most actions can be wound treatment, antibiotics, tetanus, analgesic. Installation of temporary immobilization and then sent to a referral hospital. Most of the victims to seek help because of life-threatening crush syndrome, hypothermia, pneumotorak, abdominal trauma, or pelvic trauma. Do not forget that the treatment of victims of comorbidities such as angina pectoris pain. Severe injuries or crushed by heavy objects need to be performed resuscitation. The team must immediately release the victims from the rubble crush or heavy objects in conjunction with the primary resuscitation and examination and to prevent sudden death due to hyperkalemia or hypothermia. The team should be able to care for the victim to death and cause of death as the documentation to be analyzed in the future. Members of the victim's body parts are detached or separated must be identified and collected by the main body. Then the victims gathered to a place that has been prepared by the team. Coordination between the team and knowledge of disaster medicine is a factor that strongly supports the success of disaster management disaster. Indonesia has a high risk factor happens then the disaster medicine is mandatory and is required curriculum at undergraduate and post graduate education throughout the medical education center REFERENCE 1. Saunder KO, Birnbaum ML. Health disaster Management Guidelines for Evaluation and Research in the Utstein Style. 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