FIRST INITIAL ASSESSMENT

Disasters either originating from nature or as a result of human acts in Indonesia are very likely to occur due to one of the countries located in a meeting of 5 Earth Plates. In addition Indonesia is also located in a series of volcanoes ranging from the tip of Aceh to Maluku. While human activities such as logging, many end up with disasters such as floods, landslides and so forth.

Lately various disasters such as chemical plant fire, flood. Landslides, forest fires, volcanic eruptions, earthquakes and tsunamis have hit Indonesia. Busung lapar, diarrhea, dengue fever, aviant flu inevitable to contribute to the form of disaster in Indonesia and even polio that has been declared free in Indonesia re-emerged as a disaster. Disasters that occur can be large or small, can be local or national, can lead to damage both infrastructure and materials owned by the population, often even the disaster can threaten his helper.

One of the impacts of such damage has a direct impact on the health of the affected communities, as well as the deterioration of health facilities and their supporting facilities, affecting the disruption of community accessibility to health services that ultimately affects the health status of the affected communities.

The ability of disaster-affected communities to cope with sudden and life-threatening difficulties is a key asset in the emergency response effort to the above-mentioned disaster threat before getting outside assistance. The community's ability, preparedness and maturity demonstrate the benefits of community-based disaster management.

Patients who are seriously injured require rapid, appropriate and easy assessment and management to avoid death and disability. Understanding the area of ​​the initial assessment is the process of rapid evaluation in emergency patients directly followed by resuscitation measures. Assessment and resuscitation are based on the priority of emergency on the patient based on airway, breathing and circulation. The patient's care must be quickly recognized in the Primary Survey and immediate resuscitation action to save the patient. Complete and supplementary checks are performed on the Secondary Survey. Both the Primary Survey and the Secondary Survey are conducted repeatedly to be able to recognize the decline in the patient's condition, and to provide therapy if necessary. This action is done systematically and sequentially (sequentially) but in practice in everyday events this can be done simultaneously.

Component

The overall Initial assessment process includes:

1) Preparation of the patient2) Triage3) Primary survey4) Resuscitation5) Investigations for primary servey6) Secondary survey7) Investigations for secondary surveys8) Monitoring and re-evaluation9) Definitive therapy

While the initial understanding of the assessment is limited to include the action of triage up to the secondary survey.

Initial assessment should be done in the correct order to obtain maximum results, though in practice every day can take place simultaneously.

The steps in the initial assessment include:

1. Preparation of the patient

Good coordination between doctors in hospitals and field workers will benefit patients. The hospital should be notified before the patient is transported from the scene so that the hospital can prepare the equipment and the trauma team at the time the patient arrives at the hospital. There are 2 stages of preparation of the patient: the pre-hospital stage and the intra-hospital stage. In the pre-hospital phase is a decisive phase for patient safety, ranging from initial treatment to patient referral to appropriate hospital.

At the pre hospital stage things to consider include:

• Coordination with destination hospitals tailored to the patient's condition and type of injury
• Airway maintenance, control of bleeding and immobilization of the patient.
• Coordinate with other field officers
• In the intra-RS stage should be prepared officers and equipment before the patient arrives. These preparations include:
• Personal protective equipment
• Preparedness of equipment and room for resuscitation
• Preparation for more complex resuscitation measures
• Preparation for definitive therapy

2. Triage

Triage (triage) is an action to classify sufferers based on the severity of injuries that are prioritized based on the presence or absence of interference on A (airway), B (breathing) and C (circulation).Patients with airway problems should receive first priority treatment because airway disturbance is the fastest cause of death in patients.Triage also includes the notion of organizing referrals in such a way that the sufferer gets proper care. Two types of triage state may occur:

1. Mass calamity with the number of patients and the severity of injury does not exceed the ability of the hospital. In these circumstances patients with emergency and multi trauma problems will be treated first.
2. Mass calamities with the number of patients and the severity of the injuries exceeded the ability of the hospital. Under these circumstances the first treatment will be the sufferer with the greatest survival probability, and will require the least amount of time, equipment and energy.
3. Triage action can be done on a group of patients, in disaster or mass casualties, or in a single patient to determine the diagnosis.

3. Primary survey, resuscitation, and investigation

The primary survey or primary survey is a rapid examination of vital function in patients with severe injury with priority on ABCD, this phase must be done in a short time and the gravity of the patient should be enforced in this phase. Resuscitation action to save lives should be done immediately if the emergence of emergency in patients. Actions on the primary survey include assessment:

A Or Airway maintenance is to maintain the airway, this can be done by manual technique) or use aids (oropharynx, endotracheal pipes etc). This action may be a lot of manipulation of the neck so it must be considered to maintain stability of the collar bone.

 B or Breathing is to keep breathing / ventilation work well. Every person with severe trauma requires additional oxygen to be given to the patient in an effective way. The presence of gravity  C or Circulation is maintaining the circulation along with the action to stop the bleeding. Early recognition of signs of hemorrhagic shock and an understanding of the principles of fluid administration are very important to do so avoid the patient from delayed treatment.D or Disability is the examination to obtain the possibility of neurological disorders. E or Environment or Exposure is the examination of the whole body of the patient to see clear or visible signs of emergency that may not be visible by keeping hypotermic.During this primary survey the life-threatening circumstances should be identified and the resuscitation is done on the spot. Aggressive resis- titation and the rapid management of life-threatening circumstances are essential if the patient is to survive. Priority of emergency treatment is done based on the above sequence, but if possible it can also be done simultaneously. Priority handling for young and old age patient is same. One difference is that at a young age the size of the organ is relatively smaller, and its function has not developed optimally.

In pregnant women the priority remains the same, it's just that the process of pregnancy makes the physiological process change because of the fetus. In the elderly, due to the aging process the body's function becomes more susceptible to trauma due to the reduced power of body adaptation.

Airway + Cervical control

The smoothness of the airway is the priority of the examination. This examination includes airway obstruction that can be caused by foreign bodies, facial bone fractures, laryngeal trauma, trachea and other causes.

In this case airway maintenance can be initiated by manually opening the airway by the technique of chin lift or jaw thrust maneuvers. In addition to the need to check whether there is a blockage of airway by foreign objects / blood / and others. During the course of action, care should be taken to stabilize the collarbone, especially in multiple trauma or upper trauma. Neck bone injuries should be properly anticipated until proven to be non-existent.

In certain circumstances where the airway is difficult to maintain by regular measures it must be prepared to install a definitive airway if necessary.

Breathing + Ventilation

Good breathing and ventilation require good chest, lung and diaphragm work. Interference with one of these organs can cause respiratory and ventilation problems. The patient's chest should be opened to see chest wall expansion. Perform auscultation, percussion and palpation techniques to see any abnormalities in the patient's breathing. Every trauma patient should be given oxygen. Some acute conditions due to trauma that can cause fatal respiratory distress are: tension pneumothorak, flail chest accompanied by pulmonum contusions, massive hematothorac and open pneumothorac. This should be recognized in this phase, in the pneumothorac tension should be done immediately to save lives in the form of drain thorak for decompression purposes.

Circulation + Hemorhage control

Bleeding is a major cause of death in traumatized patients who may be treated if they receive prompt and appropriate therapy. Rapid circulation function assessment can be done by assessing awareness, skin color and pulse. Stopping external bleeding can be done during primary surveys with pressure techniques on the wound or by surgery. The body's reaction to fluid loss (bleeding) may differ:

• In the elderly the ability of compensation is much reduced so that resuscitation action should be immediately given.
• At an early age the compensation is so great that signs of circulatory failure appear slow.
• On exercise the power of compensation is greater than that of an ordinary person with a marked characteristic of less tachycardia even in hypovolemia.

Fluid resuscitation is given on the basis of the degree of shock occurring, from the degree of shock and its response to fluid resuscitation, it can be predicted whether a bleeding (especially internal bleeding) requires surgical resusitation.

Disability

Rapid neurological examination can be done by AVPU method (Allert, Voice response, Pain response, Unresponsive).

Periodic GCS checks can be performed for more detailed results in the secondary survey. Decreased consciousness can be due to decreased oxygenation or decreased perfusion to the brain, or due to direct trauma to the brain. If hypoxia and hypovolaemia in patients with impaired consciousness can be excluded, consider CNS damage to the point.

Exposure

Examination of all parts of the body should be accompanied by measures to prevent hypothermia. Installation of splints or vacuum mats to stop bleeding can also be done in this phase.

Investigations are generally not conducted on the primary survey. The primary surveys are: oxygen saturation check with pulse oxymetry, cervical photo, thoracic photo, and plain abdominal photo. Other actions that can be done in the primary survey are the installation of ECG, catheter and NGT monitors. Examination done without stopping / delaying the primary survey process.

Definitive therapy and referrals

Definitive therapy is generally the job of a surgeon. The duty of the physician who performs the first treatment is to perform resuscitation and stabilization as well as prepare the patient for the conduct of definitive actions or to be referred. The referral process should have started when the reasons for referring are found, because delaying referrals will elevate the patient's morbidity and mortality. The decision to refer the patient is based on the patient's ata or physiology, anatomical injury, injury mechanisms, comorbidities and factors that may alter prognosis. Ideally selected the nearest hospital that matches the condition of the patient.

INDONESIAN INTEGRATED EMERGENCY SYSTEM

Since 2000 the Ministry of Health has developed the concept of Integrated Emergency Management System (SPGDT) integrating emergency care from pre-hospital level to hospital level and referral between hospitals with cross-program and multisectoral approach. Emergency response emphasizes prompt and precise response to the principle of Time Saving is Life and Limb Saving. It is a system where coordination is a major element of a multi-sectoral nature and there must be support from various professions are multi-disciplinary and multi-profession to carry out and organize an integrated service form for emergency patients either in everyday situations or in disasters and outside events ordinary.

In providing SPGDT medical service is divided into 3 sub-systems, namely: pre-hospital service system, hospital service system and inter hospital service system. These three sub-systems cannot be separated from each other and are interrelated in the implementation of the system.

The principle of SPGDT is to provide fast, accurate, and precise services, where the purpose is to save lives and prevent disability (time saving is life and limb saving) especially this is done before being referred to the intended hospital.

MEDICAL SERVICE SYSTEM PRE-HOSPITAL

1. Public Safety Center

In the implementation of pre-hospital service system should establish or establish a service center that is general and emergency in which the form is a unit of work called Public Safety Center (PSC), this is a work unit that provides public services, especially the emergency can be UPT District Health Offices or Municipalities, whose day-to-day operations are headed by a director. In addition, pre-hospital services can also be done by forming a special unit that served in the handling of disasters where at this time often called the Disaster Prepared Brigade (BSB), ambulance services, and communication. In the implementation of the Public Service Center can be done by the community for the benefit of the community, where the organization under local government, while the human resources consist of various elements, such as health elements, firefighting elements, police elements, elements of community and community itself engaged in the field of relief first, so it has a fast response function in emergency response response.

2. Disaster Alert Brigade (BSB)

Is a special unit that is prepared in the pre-hospital handling, especially related to health service in disaster management. Organizing is formed by health personnel both at central and regional levels (depkes, dinkes, hospitals) medical officers both doctors and nurses as well as non-medical personnel both sanitarian nutrition, pharmacy and others. Financing is obtained from designated agencies and included in the regular budget of APBN and APBD.

3. Ambulance Service

Integrated service activities within a coordination that empowers ambulances belonging to puskesmas, private clinics, maternity houses, public and private hospitals, private and government health institutions (PT Jasa Marga, Jasa Raharja, Police, PMI, Foundation and others). Of all these components will be coordinated through a service center that is mutually agreed between the government and non-government in order to carry out ambulance mobilization especially in case of mass casualties.

4. Communication

In carrying out the daily emergency service activities require a communication system where the nature is the formation of network delivery of coordination network information as well as network of emergency services so that all activities can take place in a unified system coordinated into one unity of activities.

DISASTER MEDICAL SERVICES

Service in a state of disaster that causes mass casualties requires special things to do. The things that need to be done and organized are:

1. Coordination and Command

In the event of a disaster, a pattern of activities involving cross-sectoral activities is required which will be effective and efficient if it is within a commander and a coordination agreed upon by all the elements involved.

2. Escalation and Resource Mobilization

This activity is the handling of disasters that result in mass casualties that must carry out escalation or various upgrades. This can be done by mobilizing human resources, mobilizing facilities and facilities and mobilizing all supporters of health services for victims.

3. Simulation

Required provisions are mandatory (protap) procedures, operational guidelines (juklak) and technical guidelines (technical guidelines) that must be implemented by officers who are the standard of service. The provision needs to be assessed through a simulation in order to know whether all systems can be implemented in the reality of the field. 

4. Reporting, Monitoring and Evaluation

Disaster management needs to be done documentation activities, in the form of reporting both manual and digital and accumulated into one data used for monitoring and evaluation, whether the success or failure, so that the next activity will be better.

HOSPITAL MEDICAL SERVICE SYSTEM

Care should be given to the provision of suggestions, infrastructure that must exist in the ED, ICU, mortuary, investigation units, such as radiology, laboratories, clinics, pharmacy, nutrition, inpatient rooms, and others.

1. Hospital Disaster Plan

Hospitals should make a plan to deal with catastrophic events called Hospital Disaster Plan, either in the hospital or external hospital.

2. Emergency Unit (ER)

In the ER there must be a good and complete organization of financing, trained human resources, facilities with good standards, medical and non medical facilities and following medical services technology. The main principle of service in the ER is the response time of both national and international standards.

3. Disaster Preparedness Brigade RS (BSB RS)

In the hospital should also be in the form of Disaster Preparedness Brigade which is a special task force that has the duty to provide medical services during times of disaster both in hospital and outside the hospital, where the nature of this incident caused mass casualties.

4. High Care Unit (HCU)

A form of hospital service for stable patients with both hemodynamic respiration and consciousness levels, but still requires strict and continuous care and monitoring treatment, this HCU should be present in both type C and type B hospitals.

5. Intensive Care Unit (ICU)

It is a multi-disciplinary hospital service. It is special to avoid death threats and requires a variety of tools to improve vital functions and requires sophisticated technological means and considerable financing.

6. Chamber of the Bodies

Services for patients who have died, both dead in hospitals and outside hospitals, under normal circumstances or disasters. At the time of the mass occurrence in need of organizing a complex which will be done identifying the victims both known and unknown and special human resources specialize in addition to relating to matters of legality aspect.

MEDICAL SERVICE SYSTEMS TRANS HOSPITAL

A referral network is created based on the ability of the hospital to provide services both in terms of quality and quantity, to receive patients and this is closely related to the ability of human resources, the availability of medical facilities in the ambulance system.

1. Evacuation

Forms of transport services directed from command posts, field hospitals to referral hospitals or hospital transportation, both due to disasters occurring in hospitals, where patients must be evacuated to other hospitals. Implementation of evacuation must still use standardized means to meet the criteria that determined based on hospital service standards.

2. Terms - evacuation conditions

• The victim is in the most stable state possible to be evacuated • The victim has been prepared / given adequate equipment for transportation.
• Recipient health facilities are notified and ready to receive victims.
• The vehicles and escorts used are the most feasible.

3. Some forms of evacuation

Land evacuation, in which the victims must be rapidly displaced, because the harmful environment, life-threatening circumstances, require immediate relief, as well as if there are a number of patients with life threats requiring help.
Immediate evacuation, the victim must be handled immediately, because of the existence of a stroke for his soul and can not be done in the field, such as patients shock, stress patients environment events and others. Also dilaukan pad patients who are in the environment that resulted in the patient's condition quickly decreased due to rain, cold or hot temperatures.
The usual evacuation, in which the victim is usually not threatened, but still needs help at the hospital, where the patient will be evacuated when it is in good or stable condition and is possible to move, especially in fracture patients.

4. Control traffic

To facilitate the safeguarding of evacuations, traffic control should be carried out by the police, to ensure traffic between hospitals and medical posts and command post. The medical post may convey to the command post so that the patient can be evacuated if it is in a stable state. So the traffic control must be in line with the evacuation process itself.

Successful Emergency Handling Depends 4 Speed:

1. Speed found the presence of GD sufferers
2. Speed and Response Officer
3. Ability and Quality
4. Speed Ask for Help

The possibility that occurs if late resuscitation

0- 4 Minutes	Dead Clinical	Damage Brain cells are not expected
4-8  minutes		There may already be Damage to Brain Cells
8-10 minutes	Dead Biological	Already Begins Brain Damage
> 10 minutes		Almost certainly occurs Damage to brain cells

TRANSMISSION COORDINATION EMERGENCY RESPONSE UNIT