Emergency Emergency Medicine and Medicine and the the Role Role

of of the the nternist nternist

Emergency Emergency Medicine and Medicine and the the Role Role
of of the the nternist nternist
Aru W. Sudoyo, FNASM, FACP
President
ndonesian Society of nternal Medicine
(PAPD)
Emergency Emergency : Definition : Definition
NOUN:
pl. emergency
A serious situation or occurrence that
happens unexpectedly and demands
immediate action.
A condition of urgent need for action or
assistance: a state of emergency.
NOUN:
pl. emergency
A serious situation or occurrence that
happens unexpectedly and demands
immediate action.
A condition of urgent need for action or
assistance: a state of emergency.
Emergency Emergency : Definition : Definition
NOUN:
pl. emergency
A serious situation or occurrence that
happens unexpectedIy and demands
immediate action.
A condition of urgent need for action
or assistance: a state of emergency.
NOUN:
pl. emergency
A serious situation or occurrence that
happens unexpectedIy and demands
immediate action.
A condition of urgent need for action
or assistance: a state of emergency.
Why are skills in emergency medicine
important?
Why are skills in emergency medicine
important?
DSASTER MANAGEMENT DSASTER MANAGEMENT
mpact of a Disaster
1. Large numbers of people who are
suddenly ill or injured can exceed the
capacity of the local health care system
to care for them.
2. System itself can become a victim of the
disaster. Hospitals may be damaged,
roads blocked, and personnel may be
unable to perform their duties.
3. Loss of these resources occurs at a time
when they are most critically needed.
1. Large numbers of people who are
suddenly ill or injured can exceed the
capacity of the local health care system
to care for them.
2. System itself can become a victim of the
disaster. Hospitals may be damaged,
roads blocked, and personnel may be
unable to perform their duties.
3. Loss of these resources occurs at a time
when they are most critically needed.
mpact on Medical System
1. Can hamper ability to provide routine, non-
emergency health services.
2. Many people may be unable to obtain care
and medications for their ongoing health
problems.
3. Disruption of routine services can result in
an increase in illness and death in
segments of the population that might not
have been directly affected by the disaster.
1. Can hamper ability to provide routine, non-
emergency health services.
2. Many people may be unable to obtain care
and medications for their ongoing health
problems.
3. Disruption of routine services can result in
an increase in illness and death in
segments of the population that might not
have been directly affected by the disaster.
used on Epected Sround AcceIerution
Selsmlc Pazard Map : lndonesla
USGS
RSK / HAZARD to Hospitals in ndonesia
1. Earthquake & Tsunami.
2. Volcano The Ring of Fire.
3. Floods & Hurricane.
4. Avalanche.
5. Fire
6. Riots (Demo, Ethnic / Religiousconflicts,
Political
7. Terrorism & War
8. nfectious Diseases & Epidemics
RSK / HAZARD to Hospitals in ndonesia
1. Earthquake & Tsunami.
2. Volcano The Ring of Fire.
3. Floods & Hurricane.
4. Avalanche.
5. Fire
6. Riots (Demo, Ethnic / Religiousconflicts,
Political
7. Terrorism & War
8. nfectious Diseases & Epidemics
8ole of Lhe lnLernlsL as
non-surglcal personnel
8ole of Lhe lnLernlsL as
non-surglcal personnel
"SPECAL POPULATONS "SPECAL POPULATONS
THE ELDERLY
PREGNANT WOMEN
MULT-DSEASE
NON-COMMUNCABLE DSEASE
DISASTER VICTIMS
THE ELDERLY
PREGNANT WOMEN
MULT-DSEASE
NON-COMMUNCABLE DSEASE
DISASTER VICTIMS
(BLS)
Layman
(MFR, CSSR)
Police
Fire Brigade
Security Guard
Civil Defense
Scouts
Red Cross
(Paramedic ,
CSSR)
Emergency
Ambulance
Service
Access
Emergency
Telephone Number
110,113,118
Pre-HospituI Phuse
DISASTER
Triage
NOUN:
A process for sorting injured people into groups
based on their need for or likely benefit from
immediate medical treatment. Triage is used in
hospital emergency rooms, on battlefields, and at
disaster sites when limited medical resources must
be allocated.
NOUN:
A process for sorting injured people into groups
based on their need for or likely benefit from
immediate medical treatment. Triage is used in
hospital emergency rooms, on battlefields, and at
disaster sites when limited medical resources must
be allocated.
(BLS)
Layman
(MFR, CSSR)
Police
Fire Brigade
Security Guard
Civil Defense
Scouts
Red Cross
(Paramedic ,
CSSR)
Emergency
Ambulance
Service
E.D.
I.C.U Ward
HOPE
"Emergency Nurse"
(BTLS, BCLS, BNLS, BPLS)
"Emergency Physician"
(ATLS, ACLS, ANLS, APLS)
Surgeon / Trauma Surgeon
(ATLS, BSS, DSTC, Peri OP CC)
DISASTER MANAGEMENT
Access
Emergency
Telephone Number
110,113,118
Pre-HospituI Phuse
Public
Health
Center
Rehabilitation
DISASTER
HospituI Phuse
(BLS)
Layman
(MFR, CSSR)
Police
Fire Brigade
Security Guard
Civil Defense
Scouts
Red Cross
(Paramedic ,
CSSR)
Emergency
Ambulance
Service
E.D.
I.C.U Ward
HOPE
"Emergency Nurse"
(BTLS, BCLS, BNLS, BPLS)
"Emergency Physician"
(ATLS, ACLS, ANLS, APLS)
Surgeon / Trauma Surgeon
(ATLS, BSS, DSTC, Peri OP CC)
DISASTER MANAGEMENT
Access
Emergency
Telephone Number
110,113,118
Pre-HospituI Phuse
Public
Health
Center
Rehabilitation
DISASTER
HospituI Phuse
(BLS)
Layman
(MFR, CSSR)
Police
Fire Brigade
Security Guard
Civil Defense
Scouts
Red Cross
(Paramedic ,
CSSR)
Emergency
Ambulance
Service
E.D.
I.C.U Ward
HOPE
"Emergency Nurse"
(BTLS, BCLS, BNLS, BPLS)
"Emergency Physician / Internist"
(ATLS, ACLS, ANLS, APLS)
Surgeon / Trauma Surgeon
(ATLS, BSS, DSTC, Peri OP CC)
DISASTER MANAGEMENT
Access
Emergency
Telephone Number
110,113,118
Pre-HospituI Phuse
Public
Health
Center
Rehabilitation
DISASTER
HospituI Phuse
Position of GP / nternist
DISASTER
30 - 50 meter
>< wind
Management
Support
Command & ControI
* Security
* Rescue
* AmbuIance
Triage & Stabilisation
Medical Support
(Aryono Poesponegoro)
* Security
* Rescue
* AmbuIance
bIack red yeIIow green
DISPATCH
heIipud
Nobile Ned.
Team ?
Triage & Stabilisation
Medical Support
Position of non-surgical medical personnel
non-naLural ulsasLer :
PosplLal SeLLlng
non-naLural ulsasLer :
PosplLal SeLLlng
KUNJUNGAN PASIEN GAWAT DARURAT PERIODE
JANUARI - JUNI 2008
0
200
400
600
800
1000
1200
1400
Januari Februari Maret April Mei Juni
BEDAH
NON BEDAH
ANAK
JWA
KEBDANAN
Emergency nstallation (GD) RSCM
Lmergency lnsLallaLlon (lCu) 8SCM
KUNJUNGAN PASIEN GAWAT DARURAT PERIODE
JANUARI - JUNI 2008
0
200
400
600
800
1000
1200
1400
Januari Februari Maret April Mei Juni
BEDAH
NON BEDAH
ANAK
JWA
KEBDANAN
KUNJUNGAN PASIEN GAWAT DARURAT PERIODE
JANUARI - JUNI 2008
0
200
400
600
800
1000
1200
1400
Januari Februari Maret April Mei Juni
BEDAH
NON BEDAH
ANAK
JWA
KEBDANAN
Lmergency lnsLallaLlon (lCu) 8SCM
KUNJUNGAN PASIEN GAWAT DARURAT PERIODE
JANUARI - JUNI 2008
0
200
400
600
800
1000
1200
1400
Januari Februari Maret April Mei Juni
BEDAH
NON BEDAH
ANAK
JWA
KEBDANAN
NON-SURGICAL : HOW MANY ARE
"REAL EMERGENCIES"?
CurrenL problem world-wlde :
less procedures done by general lnLernlsLs
due Lo subspeclalLles (uSA)
CurrenL problem world-wlde :
less procedures done by general lnLernlsLs
due Lo subspeclalLles (uSA)
8CCLuu8LS 8? CLnL8AL ln1L8nlS1S ln uSA
1986 - 2006 (ln )
LlecLrocardlogram lnLerpreLaLlon
ManagemenL of mechanlcal venLllaLlon
1horacenLesls
ArLerlal puncLure for blood gas analysls
CenLral venous caLheLer placemenL
LndoLracheal Lube placemenL
LlecLlve cardloverslon
ArLerlal cannula
LlecLrocardlogram lnLerpreLaLlon
ManagemenL of mechanlcal venLllaLlon
1horacenLesls
ArLerlal puncLure for blood gas analysls
CenLral venous caLheLer placemenL
LndoLracheal Lube placemenL
LlecLlve cardloverslon
ArLerlal cannula
V2007 American College oI Physicians
8CCLuu8LS 8? CLnL8AL ln1L8nlS1S ln uSA
1986 - 2006 (ln )
LlecLrocardlogram lnLerpreLaLlon 98 - 93
ManagemenL of mechanlcal venLllaLlon 39 - 26
1horacenLesls 66 - 23
ArLerlal puncLure for blood gas analysls 32 - 17
CenLral venous caLheLer placemenL 39 - 16
LndoLracheal Lube placemenL 41 - 13
LlecLlve cardloverslon 38 - 8
ArLerlal cannula 27 - 8
LlecLrocardlogram lnLerpreLaLlon 98 - 93
ManagemenL of mechanlcal venLllaLlon 39 - 26
1horacenLesls 66 - 23
ArLerlal puncLure for blood gas analysls 32 - 17
CenLral venous caLheLer placemenL 39 - 16
LndoLracheal Lube placemenL 41 - 13
LlecLlve cardloverslon 38 - 8
ArLerlal cannula 27 - 8
Source : 2007 American College oI Physicians
ln lndonesla ?
More Lhan 2000 lnLernlsLs LhroughouL
lndonesla
More Lhan 17.000 lslands
Ceneral racLlLloners : >>>
Cannot re|y on|y on spec|a||zed |nterna|
med|c|ne ] subspec|a|t|es
8aslc skllls noL only necessary buL v|ta|
More Lhan 2000 lnLernlsLs LhroughouL
lndonesla
More Lhan 17.000 lslands
Ceneral racLlLloners : >>>
Cannot re|y on|y on spec|a||zed |nterna|
med|c|ne ] subspec|a|t|es
8aslc skllls noL only necessary buL v|ta|
SubspeclallsLs dlsLrlbuLlon
0
5
10
15
20
25
DKI 1KT MEDAN PALEMBANG SURAKARTA DI ACEH BOGOR
K-GEH
K-KV
K-GER
K-PTI
0
5
10
15
20
25
DKI 1KT MEDAN PALEMBANG SURAKARTA DI ACEH BOGOR
K-GEH
K-KV
K-GER
K-PTI
IN1LkNIS1S |n INDCNLSIA
Needed : Needed : Plan Plan of Action of Action
Training Training
Needed : Needed : Plan Plan of Action of Action
Training Training
Background : Area of Skills Background : Area of Skills
Skills in basic Iife support, incl.
diagnosis and management of shock
and basics of related procedures
dentification and management of
most common acute probIems
Assessment of the patient with
uncertan condition (undifferentiated
patient)
Skills in basic Iife support, incl.
diagnosis and management of shock
and basics of related procedures
dentification and management of
most common acute probIems
Assessment of the patient with
uncertan condition (undifferentiated
patient)
Necessary Knowledge and Basic Skills Necessary Knowledge and Basic Skills
Basic life support, pathology and
pathophysiology of various illnesses
Sufficient knowledge of
pharmacoIogy
Concepts regarding trauma, shock,
and toxicoIogy
Comprehensive skills in anamnesis,
physicaI examination, estabIishing
diagnosis, and counselling
Basic life support, pathology and
pathophysiology of various illnesses
Sufficient knowledge of
pharmacoIogy
Concepts regarding trauma, shock,
and toxicoIogy
Comprehensive skills in anamnesis,
physicaI examination, estabIishing
diagnosis, and counselling
SIGNS & SM1CMS
MLulCAL
LML8CLnC?
ChesL aln
8leedlng
Shock
ShorLness Cf
8reaLh
Change Cf
Conclousness
AcuLe
Abdomlnal aln
MLulCAL
LML8CLnC?
8lMA8? Su8vL?
PosplLal Lmergency 8esponse reparedness
Al8WA? ASSLSSMLn1
88LA1PlnC ASSLSSMLn1
Cl8CuLA1lCn ASSLSSMLn1
kIMAk
SUkVL
A8CDL
Al8WA? ASSLSSMLn1
alrway obsLrucLlon (nolsy breaLhlng sLrldor, obsLrucLlve
resplraLory paLLern)?
fallure of alrway proLecLlon (poollng of secreLlons, absence of
sponLaneous swallowlng)?
mucosal oedema (anaphylaxls) or forelgn body asplraLlon?
88LA1PlnC ASSLSSMLn1
an lncreased work of breaLhlng (Lachypnoea, accessory
muscle use, recesslon)?
hypoxla or faLlgue (cyanosls, feeble resplraLory efforL)?
pneumoLhorax, asLhma, anaphylaxls, hearL fallure,
pneumonla, or chronlc obsLrucLlve pulmonary dlsease?
Cl8CuLA1lCn ASSLSSMLn1
bleedlng (haemaLemesls, melena, concealed bleedlng)?
shock (Lachycardla, prolonged caplllary reflll Llme,lncreased
resplraLory raLe, low blood pressure)?
sepsls (any Lwo of hearL raLe 90, resplraLory raLe 20 and
LemperaLure 38C or 36C)?
acuLe coronary syndrome, hearL fallure, or arrhyLhmlas
8esusclLaLlon
and urgenL
LransporL
8esusclLaLe
and reassess
Al8WA? ASSLSSMLn1
alrway obsLrucLlon (nolsy breaLhlng sLrldor, obsLrucLlve
resplraLory paLLern)?
fallure of alrway proLecLlon (poollng of secreLlons, absence of
sponLaneous swallowlng)?
mucosal oedema (anaphylaxls) or forelgn body asplraLlon?
88LA1PlnC ASSLSSMLn1
an lncreased work of breaLhlng (Lachypnoea, accessory
muscle use, recesslon)?
hypoxla or faLlgue (cyanosls, feeble resplraLory efforL)?
pneumoLhorax, asLhma, anaphylaxls, hearL fallure,
pneumonla, or chronlc obsLrucLlve pulmonary dlsease?
Cl8CuLA1lCn ASSLSSMLn1
bleedlng (haemaLemesls, melena, concealed bleedlng)?
shock (Lachycardla, prolonged caplllary reflll Llme,lncreased
resplraLory raLe, low blood pressure)?
sepsls (any Lwo of hearL raLe 90, resplraLory raLe 20 and
LemperaLure 38C or 36C)?
acuLe coronary syndrome, hearL fallure, or arrhyLhmlas
Emerg Med J 2004,21;216 225
MANAGLMLN1 AkCACn : CkGAN DSIUNC1ICN
1. CA8ulCvASCuLA8 : ACS,A8?1PMlA
2. PLMA1CLCC? : bleedlng, Lhrombosls, LhrombocyLopenla ulC
and oncology emergency
3. LunC : A8uS, S1A1uS AS1PMA1lCuS
4. 8LnAL : A8l,ML1A8CLlC ACluCSlS / ALkALCSlS
3. CAS18C ln1LS1lnAL & PLA1C8lLlL8
6. LnuCk8ln
7. CvL8 uCSL" & ln1CxlCA1lCn
8. nLu8CLCC?: MC,S1A1uS LlLL1lCuS
9. SPCCk, AnAP?LAxlS
10. lnlLC1lCn / SL1lC
1. CA8ulCvASCuLA8 : ACS,A8?1PMlA
2. PLMA1CLCC? : bleedlng, Lhrombosls, LhrombocyLopenla ulC
and oncology emergency
3. LunC : A8uS, S1A1uS AS1PMA1lCuS
4. 8LnAL : A8l,ML1A8CLlC ACluCSlS / ALkALCSlS
3. CAS18C ln1LS1lnAL & PLA1C8lLlL8
6. LnuCk8ln
7. CvL8 uCSL" & ln1CxlCA1lCn
8. nLu8CLCC?: MC,S1A1uS LlLL1lCuS
9. SPCCk, AnAP?LAxlS
10. lnlLC1lCn / SL1lC
DIAGkAM ALUk moLlvasl
Building Learning Commitment
1eor|] wawasan
endekaLan 1anda dan Ce[ala
PenLl [anLung
Syok
8eaksl Alergl 8eraL
Slnd. ulsLres ernapasan AkuL
Ldema aru kardlogenlk
Sepsls
lnfeksl 8eraL
1romboemboll aru
LnsefalopaLl hepaLlkum
Slndrom uellrlum AkuL
keracunan
koagulasl lnLravaskular ulsemlnaLa
Metode
kullah
keteramp||an
endekaLan 1anda dan Ce[ala
PenLl [anLung
Syok
8eaksl Alergl 8eraL
Slndrom ulsLres ernapasan AkuL
Ldema aru kardlogenlk
Sepsls
lnfeksl 8eraL
1romboemboll aru
LnsefalopaLl hepaLlkum
Slndrom uellrlum AkuL
keracunan
koagulasl lnLravaskular ulsemlnaLa
PemaLemesls Melena
keLoasldosls ulabeLlkum
Metode
aLauulskusl kelompok/ kasus
PemaLemesls Melena
keLoasldosls ulabeLlkum
Cangguan Cln[al AkuL
Plpogllkemla
krlsls PlperLensl
Slnd. vena kava Superlor
krlsls 1lrold
ClglLan 8lnaLang 8erblsa
Plpokalemla
1rauma lnhalasl
Lfusl leura Mallgna
PemaLurla Maslf
1erLelan ZaL koroslf dll.
1eor|] wawasan
endekaLan 1anda dan Ce[ala
PenLl [anLung
Syok
8eaksl Alergl 8eraL
Slnd. ulsLres ernapasan AkuL
Ldema aru kardlogenlk
Sepsls
lnfeksl 8eraL
1romboemboll aru
LnsefalopaLl hepaLlkum
Slndrom uellrlum AkuL
keracunan
koagulasl lnLravaskular ulsemlnaLa
Metode
kullah
keteramp||an
endekaLan 1anda dan Ce[ala
PenLl [anLung
Syok
8eaksl Alergl 8eraL
Slndrom ulsLres ernapasan AkuL
Ldema aru kardlogenlk
Sepsls
lnfeksl 8eraL
1romboemboll aru
LnsefalopaLl hepaLlkum
Slndrom uellrlum AkuL
keracunan
koagulasl lnLravaskular ulsemlnaLa
PemaLemesls Melena
keLoasldosls ulabeLlkum
Metode
aLauulskusl kelompok/ kasus
Lvaluasl
enuLupan
PemaLemesls Melena
keLoasldosls ulabeLlkum
Cangguan Cln[al AkuL
Plpogllkemla
krlsls PlperLensl
Slnd. vena kava Superlor
krlsls 1lrold
ClglLan 8lnaLang 8erblsa
Plpokalemla
1rauma lnhalasl
Lfusl leura Mallgna
PemaLurla Maslf
1erLelan ZaL koroslf dll.
Take Home Message Take Home Message
Key to Success Key to Success
Training Training
Key to Success Key to Success
Training
Practice ..... Practice .... Practice
Training
Practice ..... Practice .... Practice
Key to Success Key to Success
Training
Practice ..... Practice .... Practice
Competent
Training
Practice ..... Practice .... Practice
Competent
Key to Success Key to Success
Training
Practice ..... Practice .... Practice
Competent
Self-confidence
Training
Practice ..... Practice .... Practice
Competent
Self-confidence
Key to Success Key to Success
Training
Practice ..... Practice .... Practice
Competent
Self-confidence
Training
Practice ..... Practice .... Practice
Competent
Self-confidence
Patient Safety = Doctor's Patient Safety = Doctor's
Safety Safety
Patient Safety = Doctor's Patient Safety = Doctor's
Safety Safety
ndonesian Society of ndonesian Society of
nternal nternal Medicine Medicine
((PAPD): PAPD):
Mission: "..to enhance the
quality and effectiveness of health
care by fostering excellence and
professionalism in the practice of
internal medicine..
Mission: "..to enhance the
quality and effectiveness of health
care by fostering excellence and
professionalism in the practice of
internal medicine..
Acknowledgements Acknowledgements ::
Prof. DR. Dr. Aryono D. Pusponegoro,
SpBD(K)
Dr. Bambang Suryono, SpAn(K)
Dr. Cosphiadi rawan, SpPD, K-HOM
Dr. Murdani Abdullah, SpPD, K-GEH
Dr. Bambang Setiyohadi, SpPD-KR
Prof. DR. Dr. Aryono D. Pusponegoro,
SpBD(K)
Dr. Bambang Suryono, SpAn(K)
Dr. Cosphiadi rawan, SpPD, K-HOM
Dr. Murdani Abdullah, SpPD, K-GEH
Dr. Bambang Setiyohadi, SpPD-KR
Thank You for Your Attention Thank You for Your Attention