DAY TO DAY EMERGENCIES

DAY TO DAY EMERGENCIES
(GAWAT DARURAT – GADAR)

Disaster & Victims


Strategy & Planning to a
SAFE COMMUNITY



Aryono D. Pusponegoro
Idrus Paturusi
Ikatan Ahli Bedah Indonesia (IKABI)


Cases :


Indonesia is a sensitive area of disaster:

1. Earthquake & Tsunami.
2. Fire mountain (The Ring of Fire).
3. Flood, Longsor.
4. Fire.
5. HAZMAT / NUBIKA Industry
6. Demonstrations.
7. Terorism, Hostage, HAZMAT/NUBIKA
8. Etnic Problems, Religion, Politic etc.

Daily GADAR also became problems that wound before becomes the reason for the main death but now coroner hearth attack, degenerative disease  & accident/Traffic accident (KLL) already becoming the main reason for death in city.


Since 1980 till 2006 there are 60 disasters with many victims such as The Earthquake & Tsunami in Aceh at the end of 2004:
Tabel 1. Disaster & Many Victims in Indonesia 1980-2006

1. GalunggungVolcano Erruption West Jawa	1980.
2. Major Food Poisening West Jakarta	1981.
3. Harbor Fire Tg Priok Jakarta	1981.
4. Major Gas Poisening Tg Priok Jakarta	1982.
5. Earthquake West Jawa	1983.
5.Hotel Fire Jakarta	1985.
6. Bouraq Airline Crash in Karawang West jawa	1985.
7. Massive Multiple Car Crashes in Toll Road Jakarta	1985.
8. Atmajaya Hospital Massive Flood Jakarta	1986.
9.Fatmawati Hospital Evacuation because of Amunition Dump Explosion Jakarta	1987.
10. Major Train Crash Bintaro Jakarta	1987.
11.Tg Priok Riots with Koja Hospital Isolated for 1 week	1987.
12. Factory Food Poisening Jakarta	1988.
13. Earthquake & Tsunami Flores	1991.
14. Political Parties Riots Jkt	1992
15. Massive Flood Jakarta 2 x	1991 & 1992.
16. Tsunami Lombok	1993.
17. Eathquake  Liwa South Sumatra	1993.
18.Merapi Volcano Erruptions (3x) Jogyakarta	1995.
19. Earthquake Kerinci	1995.
20. Political Party PDI –P Riots Jakarta	1996.
21. Earthquake & Tsunami Biak Papua	1997.
22. Earthquake South Sulawesi	1997.
23. Ethnic Conflict Pontianak Borneo	1997.
24. Earthquake Bengkulu	2000.
25. Ethnic Conflict Sampit Borneo	2001.
26. Displaced Persons caused by ethnic & religious conflicts in Madura, Poso, West Nusa Tenggara, East Nusa Tenggara, Papua, West Jawa, Middle Jawa, North Maluku, Maluku, North Sulawesi	2001.
27. Ethnic Conflict in Sampang Borneo	2001.
28.Papandayan Volcano eruption West Jawa	2002.
29. Major Train Crash in Brebes	2002.
30. Massive Landslide in East Jawa	2002.
31. Massive Flood in North Sumatra	2002.
32. Massive Flood in Semarang & Pekalongan	2002.
33. Religious Conflict Ambon	1999 – 2002.
34. Religious Conflicts Palu	1999 – 2002.
35. Papua Riots	1999 – 2002.
36. Jakarta 32 x  Terrorist Bombings & Riots	1998 – 2002.
37. Jakarta 3 weeks Massive Flood	2002.
38.Nunukan Displaced Migrant Worker.	2002.
39.Terrorist Bombing Bali	2002.
40. Terrorist Bombing Htl Marriott Jakarta	2003.
41. Chemical Factory Explosion Gresik	2004.
42. Earthquake in Nabire 2x	2004
43. Australian Embassy Terrorist Bombing Jakarta	2004
44. Aceh Earthquake & tsunami	2004 – 2005
45. Earthquake in Palu	2005
46. Earthquake West Jawa
47. Trash Dump Landslide Bandung	2005
48. Nias Earthquake	2005
49. Padang Earthquake & Volcano activity	2005
50. Anak Krakatau, T Perahu, Lokon volcano activity	2005
51. Train Crash Tg Barat Jakarta	2005
52. Lion Air Crash Solo	2005
53. Mandala Air Crash Medan	2005
54. Bali Bomb II	2005
55. Budi Asih Hospital Collapse Jakarta	2005
56. Banjir Djember	2006
57. Banjir Banjarnegara	2006
58. Banjir Bima	2006
59. Banjir & Longsor Trenggalek	2006
60. Merapi Volcano	2006
61. Jogya EQ	2006

Since 1980 to 2006, 1 to 2 disasters with many victims happened. But the problem solver seems unsuitable with the condition and even created the crowded impression especially in its Managemet Support. From all disaster and many victims, only Displaced Migrant Worker from Malaysia to Nunukan, Train Accident in Tanjung Barat Jakarta, Bali Bomb II and Budi Asih Jakarta hospital which solved with Order in Chaos because the Management Support & Medical Support was well done in Pra Hospital-Emergency Ambulance 118 (AGD 118) and Emergency Unit-Hospital (UGD-RS) phase.

Related 1986 & 1991 Kesehatan Nasional Survey, Coroner Hearth disease with the wound is the main reason for the death. Meanwhile, accident is the fourth death reason.

• Survei Kesehatan Nasional (National Health Survey) 1986 :

2,5 million of people injured and poisoned.
125 .000 were taking care in the hospital and
50.000 died. But only
4.000 died in hospitals.
46.000 THE LESS, WHERE THEY DIED?

• Survai Kesehatan Nasional (National Health Survey) 1991, Trauma/injury is the fourth death reason, but if it is grouped based on the age:

5 - 14 th ------------- No 4.
15 - 24 th -------------No 1.
25 - 34 th -------------No 2 (also pregnant women).
35 - 44 th --------------No 4
More than 45 years old died because of cardiovascular. More than 60 years old died because of degenerative disease.

• Maternal Mortality ----------- 390 / 100.000 ----------->   20.000 / th.
• Perinatal Mortality ------  40 / 1000      -----------> 160.000 / th.
• Died because of cardiovascular in Jakarta:

1991---------  2535 pts.                   1996 ------1003 pts
1992---------  2746 pts.        1997------ 1419 pts
1993---------  2961 pts.        1998-------1455 pts
1994    ------- 3255 pts.        1999------1114 pts
1995  ---------1475 pts.

• Died because of hypertension in Jakarta:

1993 --------1027 pts.        1997 -------564 pts.
1994 --------1138 pts.        1998 -------674 pts.
1995 --------1151 pts.        1999 -------737 pts.
1996 ---------215 pts.

• Died because of Kematian Cerebrovascular accident (Stroke) in Jakarta :

1993 -------1027 pts.        1997 ------1133 pts.
1994 -------1138 pts.        1998 ----- 1108 pts.
1995 -------1151 pts.        1999 -------888 pts.
1996 -------1400 pts.

• Died because of Traffic accident in Indonesia:

1991 -----10.621 pts.       1997 -----10.445 pts.
1992 ------9.819 pts.        1998 ------9.576 pts.
1993 ---- 10.038 pts.        1999 ----- 9.954 pts.
1994 -----11.004 pts.        2000 ------9.506 pts.
1995 ------ 9.251 pts.        2001 ------9.522 pts.
1996 ------ 9.346 pts.        2002 ---    8.762 pts.

• Died because of Kematian Traffic Accident/KLL in Jakarta :

Jakarta Police HQ Morgue

• 1991            345                                               1.201
• 1992            444                                               1.317
• 1993            511                                               1.349
• 1994            582                                               1.326
• 1995            521                                               1.344
• 1996            568                                               1.454
• 1997            817                                               1.568
• 1998            744                                               1.229
• 1999            403                                               1.238
• 2000            324                                               1.360
• 2001            261                                               1.330
• 2002            262                                               1.358
• 2003            503                                               1.492

The earthquake and Tsunami in Aceh already took more than 200.000 people died, but the death because of daily GADAR (Cardiovaskuler, Stroke & Traffic Accident/KKL) in Jakarta reached more than 3000 patients died. This number can be decreased to 50 % if our Daily GADAR (Pra Hospital even UGD-RS phase) is good. If this number was counted in all of Indonesia, the total of died GADAR patients can be prevented from death. Every year in Jakarta, there are 751-1069 young traffic accident’s victims  still alive when the police came to the accident place but died on the way to the hospital because Emergency Ambulance (AGD 118) supply only 40 pos and 10 AGD 118 motorcycle for 10 millions people so that the response time under 10 minutes only reaches 50%. This death cases number can be put as a barometer for the bad and good quality of GADAR solver in Jakarta.
HEALTH FACILITIES:
On the year of 2000, in Indonesia there are:

• 7000 Puskesmas
• 1500 Hospitals

Before the earthquake and Tsunami, there are 8 hospitals for around 700.000 people in Aceh. Only 1 hospital which is un Structural Collapse. The other are Functional Collapse, Zanoel Abidin hospital was full of dump, Tentara hospital was full of patients but they have been leaved by the doctors and nurses because of untrainned. Meanwhile another hospital was being emptied and did not accept patient even there were no doctors and nurses. Hospitals near to Banda Aceh actually can arrive in few hours but they did not send helps, while they waited for the main help because they did not have disaster solver system. Patient with Airway, Breathing and Circulation problems which should have survive but died because the help came more than 24 hours and the only problem is Disability. We Are Always Too Late.
There are also 2 hospitals in Meulaboh and Structural Collapse occurred in 1 hospital. One hospital is in a good condition but Functional Collapse happened because it does not have systems and Disaster Plan.
In Jakarta in the year of 2004 there are:

• 331 Puskesmas that mean should be 331 Emergency Rooms.
• 109 Hospitals mean 109 UGD.

So Jakarta is supposed to have 440 UGD for 10 millions of people which are not so bad compared to New York, Paris, London, Sidney & Tokyo. The problem is not all our UGD were trained and coordinated.
There are  40 pos/24 hours AGD 118 and 10 AGD 118 motorcycle. This really not enough for Pra Hospital Jakarta phase.
In Denpasar Bali in the Bali bombing there were no Management Support or Medical Support on the field so it became a Chaos. In the Hospital faze in RS Sanglah, the surgeons did 200 surgical actions in on night with only one death. This is because the surgeons have already been trained in Advanced Trauma Life Support (ATLS), Basic Surgical Skill (BSS), Definitive Surgery for Trauma Care, (DSTC – where they are trained for  Mamaged Control Surgery) and Pre Operative Critical Care (Peri Op CC). Before the second Bali Bomb, in Denpasar there is a training of Safe Community and Centralized Handling Emergency System. The key word is centralized. So they use everything and resources that they have. Denpasar has 18 Hospitals, that means equipped with 18 Emergency rooms, and coordinated with 18 ambulances 118 that are hospital based. That is why in the second bali bombing, there was a Management Support and Medical Support in the pre hospital faze and also in the emergency faze, the hospital and the disaster management was able to be done by Bali itself.
In Makassar there are also 24 hospitals with 24 trainned emergency rooms and 24 AGDT 118 Hospital Based.
Jogjakarta with 18 hospitals, since Merapi I erupted, 18 trainned UGD & coordinated and 18 AGDT 118 Hospital Based had been formed with Dr Suyudi SpB as RS Sarjito Director and the chief of Persi Jogjakarta. Jogjakarta proved can handle Merapi eruption by itself.
INTERNATIONAL STANDARD COURSES WHICH IS OWNED BY DOCTOR PROFFESION IN INDONESIA:

1. ATLS hold by Trauma Commision legalized by American College of Surgeons (ACS), Commitee on Trauma (COT). From this courses Basic Trauma Life Support (BTLS), Pre Hospital Trauma Life Support (PHTLS) for the Paramedics and Basic Life Support (BLS) for people were developed.
2. ATLS is held by Trauma Commision IKABI which is legalized by American College of Surgeons (ACS), Commite on Trauma (COT). From this course Advanced Cardiac Life Support (ACLS) by PERKI and Basic Cardiac Life Support (BCLS), Pre Hospital Life Support (PHCLS) and BLS were developed.
3. ATLS held by Trauma Commission IKABI legalized by American College of Surgeons (ACS), Committee On Trauma (COT). From this course Advanced Neurologic Life Support (ANLS) by PERDOSI and Basic Neurologic Life Support (BNLS), Pre Hospital Neurologic Life Support (PHNLS) were developed.
4. 4. Advanced Pediatric Life Support (APLS) by IDAI and Basic Pediatric Life Support (BPLS) , Pre Hospital Pediatric Life Support (PHPLS), Pediatric Emergency Transport (PET) & Neonatal Emergency Transport (NET) were developed.
5. 5. BLS by AGD 118.
6. 6. Medical First Responder (MFR) by AGD 118, from USAID.
7. 7. Collapsed Structure Search & Rescue (CSSR) by AGD 118 from USAID.
8. 8. Major Incident Medical Management Support (MIMMS) by AGD 118.
9. 9. Hospital Preparedness for Emergencies & Disasters (HOPE) special for hospital management was held by IKABI coordinated with PERSI. HOPE course holds by Indonesia, Filipina, India & Nepal with USAID help. IKABI joins with PERSI specially hold management hospital. HOPE course is held by MIMMS (used by England & Europe), meanwhile Hospital Emergency Incident Command System (HEICS) which used in USA is not worked in Indonesia and other developed countries because there is no infrastructure.  That is why in HOPE course is focused to the infrastructure forming that is Sistim Penanggulangan Gawat Darurat Terpadu (SPGDT)/Unity Emergencies Prevention System that issued by ATLS instructors in Surabaya 1997 meeting. Beside SPGDT

Selain SPGDT, manajemen RS diberi pengetahuan & kemampuan untuk menilai apakah RSnya akan terjadi Structural Collapse bila terjadi gempa, banjir dan kebakaran dan cara me Reinforce nya. Juga untuk menilai setelah kejadian apakah perlu evakuasi RS atau tidak. Selain itu juga dilatih untuk membuat Disaster Plan, sehingga siap menghadapi day To Day emergencies, Bencana & Korban Masal. Juga cara melaksanakan Management Support & Medical Support supaya tidak terjadi Functional Collapse dari RS maupun di Pra RS. Menegakkan Command & Control terutama di Pra RS karena antara Polisi (Security), Dinas Kebakaaran (Rescue), dan AGD 118 tidak ada Horizontal Control.

1. 10. Perawat di UGD dapat diberi pelatihan BTLS, BCLS, BNLS, BPLS dan Disaster Management maka mereka akan mendapat sertifikat “Emergency Nurse” dari PPNI.

Dokter Umum di UGD dengan pelatihan ATLS, ACLS,
ANLS, APLS dan Disaster management akan mendapat
sertifikat “Emergency Physician” dari Perhimpunan
Dokter Emergensi Indonesia (PDEI –IDI). Dengan
demikian mereka akan mampu menanggulangi Day to
Day Emergencies, Bencana & Korban Masal.
Keuntungan pola pelatihan ini adalah dapat
dilaksanakan dalam waktu singkat bila ada sponsor dan
dapat juga dicicil bila tidak ada sponsor.

1. 11. Brigade Siaga Bencana (BSB). Para dokter umum anggota BSB sebaiknya dilatih sebagai “Emergency Physician”. Dengan demikian dalam keadaan sehari – hari mereka dapat bekerja di UGD sebagai “Emergency Physician”, dan juga dilatih sebagai manajer UGD diluar jam kerja dengan tanggung jawab UGD berjalan lancer, tidak ada pasien yang terlantar & tidak ada kekurangan alat kesehatan maupun obat. Ini dilakukan dengan Data collection, Data Analysis, Decision, Evaluation. Dalam keadaan bencana & korban masal mereka akan bekerja sebagai Management Support dengan melakukan Data Collection, Data Analysis, Decision & Evaluation mengeni jumlah pasien, jenis penyakit & vektornya, Logistik medik maupun non medik, personel medik & non medik, penginapan, dapur dll. Sedangkan Medical Support dilakukan para spesialis dengan para peserta program pendidikan dokter spesialis (PPDS) dari setiap pusat pendidikan dokter spesialis.

Dengan pelatihan seperti di atas, selesai masa tugas di BSB, mereka dapat melanjutkan studi spesialisasi karena sudah mempunyai semua sertifikat yang dibutuhkan dan kalau melamar pekerjaan pun akan mendapat pekerjaan yang layak. Dokter yang akan bekerja di Puskesmaspun dilatih seperti diatas sehingga mereka dapat melayani masyarakat dengan baik demikian juga kalau terjadi bencana / korban masal mereka tahu apa yang harus dilakukan. Ini juga merupakan bonus bagi masa depan mereka yang sudah mengabdi kepada masyarakat. 
12. For all the general surgeons and other specialist by participating in ATLS,BSS,DSTC,Peri Op CC and disaster management and being a instructor in all of the courses they will be able to be Trauma Consultants because will have the knowlegde on the science of Traumaology and other experiences as a surgeon.

1. 13. PARAMEDICS.   Indonesia follows the Nurse Paramedic method where their basics are nurses. Abroad they are usually trained for 3 years in an on the job training. At the Paramedic training center AGD 118 Jakarta (the only in Indonesia) education is done through 2 semesters: Nurse Academy / Midwives – Nurse Paramedic.

ß Basic Paramedic Skills (Induction Program, BLS, MFR, CSSR, Defensive Driving. Equal to Emergency Medical Technician Basic (EMT Basic) / Paramedic I
ß Emergency Nurse (BTLS, BCLS, BNLS, BPLS & Disaster Management
ß Internship in the Emergency room, (Intubation under Anestation surveilance di bawah), ICU, ICCU, Perinatology, Burn Wounds, Stroke Center, Obgyn, Psichiatry dll. Equal to EMT Intermediate / Paramedic II
ß Dispatcher.
ß PHTLS, PHCLS, PHNLS, PHPLS / PET & NET, Disaster Management (the science)
ß Work Health.
A certifcate from Medicine Faculty (Diploma) is equal to a EMT Paramedic / Paramedic III
They will be able to approach and handle usual emergencies also disaster and mass casualties in a pre hospital fase with AGD 118 Basics (immediate reaction response and Airway tools,breathing,circulation, disabilty and exposure that are non invasive), and AGD 118 motor unit, on the road, highway, home,office, buildings, hotel, factories and mining areas.
SAFE COMMUNITY & SPGDT :
If we combine all of the health infrastucture that are located in the village and city also in all of the provinces with all of the international standard courses then it will shape into a SAFE COMMUNITY in every village (on alert village), city, building,hotel, factory and mining area. Which basically all of the above is one whole community.
With that in mind it is expected that all cities and, districts and provinces can be able to handle usual basic emergencies and also disasters with mass casualties within the first 24-48 hours before recieving help and aid from the outside like Denpasar & Yogyakarta (You Are On Your Own – YO YO 24 – 48 Hrs)
MONITORING:

1. Every hospital has to have a Disaster Plan that can be accredited in to the hospital every 3 years and have a simulation of the disaster pre faze minimum every 1 year.
2. Every village, city, community, district and province has to have a disaster plan and simulation of this plan once every year.
3. Response Time (quick response) AGDT 118 should be under 10 minutes in normal emergencies and disaster emergencies in collaboration with the security and search and rescue team.
4. The mortality and casualty rates in emergencies normal and disasters will decline.

PROGRAM :
Training should be done in 32 provinces in a gradually in a faze manner and done accordingly through the Risk and Threat (HAZARD) that every province will go through.

Emergency Management System :
HOPE
Emerg Nurse
(BLS)            (BLS +,          (Paramedic /   Emerg Physician
MFR, CSSR    MFR)              SpB (K) Trauma
Normal             Police   AGD 118             ER     ICU       WARDS
Fire Department
Local Security
Security
Police Enforcer
PhoneLine                                 Rehabilitation
Emergency :
110-Security
113-Rescue                                                      118-             118 - AGD 118
Puskesmas
The Right Patient To The Right Hospital By The Right Ambulance At The Right Time
Pre Hospital Faze                                         Emergency Faze

1. 1. The training of this program should be started with HOPE because the directors of the hospitals are Agents of Change IKABI have trained ATLS to 11.000 docters, Perki have trained 5000 docters ACLS and AGD 118 have trained 7000 nurses in BTLS & BCLS but still with no improvement in emergencies, disasters because in truth the hospital directors are the ones in charge of the emergency rooms and ambulance unit. With their awareness and responsibility on handling the emergencies then it will gradually shape into a SAFE COMMUNITY and SPGDT / AGDT 118
2. Training Emergency Nurses and Physicians, BLS (normal), BLS (+) / MFR (for special cases (Police, Fire Department, Security and Police Enforcers), MFR (equal to EMT Basic – Paramedic I / Paramedic school in AGD 118 Jakarta and simulations on disasters and done simultaneosly in 14 days. .
3. AGDT will always need fundings and if the directors of the hospitals are replaced there will be a possibilty that they will also not agree with the AGDT 118. With that in mind the AGDT 118 should be developed into a AGD 118 with local heads, Governor , local government, IKABI, PERSI, Police, Fire Department, Social and Health Insurance. This will be a place where everyone can sit and discuss also develop the SAFE COMMUNITY program they are facing. Other from that the governor and Local Government can have access and purchase these infrastructures for the AGD 118 and donate them to the AGD 118 organization with coordination with the Health and Social Insurance Organization so that it will be allocated properly.