Me First please.....

                                                                 ( mysafety1st.com)
                           

   Triage is the concept that is introduced by Napoleon’s battlefield surgeon. The concept stress on the need for us to treat the most seriously injured to receive the care first. This concept is usually needed in the case of mass disaster. Disaster mentioned here can be natural disaster such as cyclones or manmade disaster such as bombing. In mass disaster, the resources available to provide greatest conventional care for each individual injured usually are not sufficient. So, patient that seriously needs the care must be treated first in order to increase the chance of survival.

   Basically, triage can be divided into five categories: Immediate, delayed, minimal (walking wounded), expectant and dead. In the initial phases, only two phases are considered important: immediate or non-immediate. Immediate category . Later, more categories can be defined when the casualties influx subsides and nature and extend of injuries and resources are known, and more evaluation are carried out.

   Patients who are classified into immediate category must be treated first because they are having life-threatening case. There are many examples of life-threatening case such as open chest wound, tension pneumothorax, airway compromise, unconsciousness with focal signs, hypotension, active external haemorrhage and intermediate burn. These conditions can be treated by simple intervention such as rapid external wound compression, laparotomy for splenectomy, endotracheal intubation, tube thoracostomy that would stabilize patient immediately after the intervention. These interventions are not only life saving but can also give more space for other patients that are belong to the same category to be treated as soon as possible. 

        Other category is delayed. Patients with extremity vascular compromise, spinal fractures with or without spinal cord injury, pelvic fractures, open or closed extremity fractures, penetrating torso fractures, soft tissue wounds, unconsciousness without airway compromise or lateralizing signs and etc are classified into this group. Continuous monitoring is needed and intervention such as IV infusion, volume repletion, administration of analgesics and antibiotics, covering open wounds are immobilizing fractures can reduce the morbidity. These interventions are included in minimal acceptable care. Patients must be placed in the area in which the immediate patients group are placed to avoid crowding and confusion.

     The minimal group is the one who always arrive at the hospital early because of their ability to walk using their own power. Patients in this group are usually do not need intensive treatment but may require first aid treatment. Medical team must monitor these patients for any deteriorating conditions.

    Expectant is related to the patients with the conditions that are serious with low chances of survival but are still alive. This condition may confuse us from giving the right treatment to the patient classified into immediate group that are more beneficial. The examples of conditions that classified into expectant condition are serious head injuries with open skull fractures or unconsciousness, extensive and deep burns and imminent cardiac arrect with major torso trauma. They basically need to be monitored for any improvement that may warrant care as well as kept comfortable.

  The last but not least is the dead category that is important to be differentiated from other group to prevent unnecessary resuscitation and intervention. Moreover, the process will make later processes of identification as well as communication to the family of the dead person easier.

References:
1. E.R. Frykberg. Triage: Principles and Practice. 2005.   [online accessed on November 28rd
 2010]
URL: http://www.fimnet.fi/sjs/articles/SJS42005-272.pdf

I need your help!!!!

 

   Identification of the dead body is very important before we can release the body to the family. Forensic medicine is a branch in medicine that help in identification of the dead body as well as the cause and manner of death, the date and location and other information that cannot be obtained from ante mortem sources. In this topic, I would focus on the forensic odontology in identification of the dead body. As we know that the dead body cannot speak and tell us what was going on them before the death and has been waiting for us to investigate the case related to them, so that, we can produce sufficient evident to fight for them in criminal case. Why dental odontology one of the important branch? According to my lecturer, dr. Yudha, fingerprint, dental profile and DNA can be used as primary evidence whilst secondary evidences that can be used include visual, photography, properties and medic-anthropology data. Why teeth can provide a very useful information? This is because teeth are the hardest part in our body – the enamel. In many cases, teeth remain intact. The data can be collected from ante mortem as well as post mortem basis. As we know, we two phase in teeth development. The second phase is the development of permanent teeth that is usually develops in the first decade. Human basically can have up to 32 permanent teeth with 5 surfaces each. The surfaces can be either filled with restorative materials or not. Basically, people around the world do have visit to dentist at least once in their lifetime. The purpose of visiting varies such as just for routine check up, treatments or check for disorders. This may give the opportunity to dentist to develop a record of the patient regarding their teeth characteristics during life. Other than that, other data such as radiograph, study models and dental photographs can provide better ante mortem data to the forensic team. The effectiveness of the ante mortem data relies on many factors such as accuracy of the record and the storage of the data. In some places, data that are stored in the form of paper maybe destroyed by certain situation such as tsunami. But what happened when ante mortem data is not available even though we know that it has large contribution to the identification together with post mortem data? In this case, post mortem data alone can also contribute something such as the age of the person at time of death, socio-economic status, unusual oral habit and type of diets. 

 

 

In mass disaster, there are usually many dead bodies presented at time. If only 12 bodies, it may be possible to use other method as combination. If the dead bodies are too many such as in the case of tsunami, what can we do to perform quick identification? Forensic odontology is the answer because it is simple and inexpensive method. Compared with DNA method, DNA method is very expensive, need sophisticated technology as well as need longer time. Moreover, the infrastructures as well as transportations are damaged during disaster, making the process of identification more difficult. For further info, it may be useful to refer to my previous post: unpredictable situation.

How about birthmark analysis? What is the use of this? Basically, it can be used in crime scene investigation. It is can be used to differentiate whether the purpose of the perpetrator are sexual, child abuse or other assaults forms.

In conclusion, forensic odontology is a useful method in many cases such as mass disaster, domestic violence and child abuse. More specialist is need because we are now facing unpredictable natural and manmade disaster that cause mass disaster.

References:
1. Amad, H.S. Forensic Odontology. [online accessed on November 26th 2010]
URL: http://www.smile-mag.com/art_files/Forensic_Odontology.pdf
2. Stavrianos, C. Et al. Application on Forensic Dentistry: Part 1. [online accessed on November 26th 2010]
URL: http://docsdrive.com/pdfs/medwelljournals/rjmsci/2010/179-186.pdf

Long term commitment.

                                                                   (pointblank-dm.com)

        The title above is related to chronic disease management. For this topic, I would explain how we can improve chronic disease management at different levels in our health system. This topic is important because chronic diseases such as heart disease, diabetes mellitus or stroke have been increasing in low, middle and high income countries. People now are living longer even though they are having disease that cannot be cured. This phenomenon occurs due to the advance in health care and technology. Before we go into details related to chronic disease management, I would like to give some definitions. According to WHO, chronic disease is the diseases of long duration and generally has slow progression. CDC has different version of definition. According to CDC, chronic disease is a disease that cannot be cured once acquired. Other than that, criteria of having the condition for three months or longer are included in this definition. There are many risks of developing chronic diseases such as physical inactivity, unhealthy diet and tobacco use that are modifiable and age and hereditary factors that are non-modifiable.

Management.
Chronic disease management is defined as systematic approach to coordinating health care intervention across the levels (individual, organizational, local and national). Three main levels underpinning by population-wide disease prevention and health promotion are formulated from Kaiser Permanente care triangle. These include the self supporting care, disease management and case management. The management as mentioned above focus on three levels.

      The first level is the individual levels. There are many approaches that can be used at this level such as psychological and behavioural theory, stages of change model and some of the case managements. Stage of changes is one of the effective methods used and originated from the intervention of smoking cessation as well as alcohol and drug addiction. There are five levels in this approach including pre-contemplation, contemplation, decision, action and maintenance. These processes can take place in many setting such as in the hospital. Other than that, telephone can also be used as one of the individual proactive support. This is proven by United States. Even though some approaches seem to be simple, but that does not mean that they are easy to be carried out. A lot of considerations such as the affordability of individual, the availability of the technology, the accessibility of population, cultural view and etc should be taken into account. Moreover, we can take one of the examples in stage of changes that involved nurses as care managers, physician and specialist working together. This study was carried out in the one of the region in Italy. This study used team-based model and stage of change.  The stage of change was carried out by nurses who supported patient with regular motivation and reminders, acts as signposting service to other resources and coordinate care for individual at general practices. This intervention used face-to-face approaches rather than telephone.

 

                                                                          (fachc.org)

      The second level is the delivery-level initiative. The concept of generic chronic care model originated from US is now being adapted to Europe countries. This concept consists of six interdependence components that are important in chronic care management: health care organization, decision support system, self management support, clinical information system design and resources and policies. Some governments have provided incentives for improving the health care management in chronic disease case as well as new risk adjustment mechanism.

The third level is the system wide initiatives. There are many countries implementing service delivery policies even though they aspire to system wide approach. In order to carry out this approach, we need to understand about the scope of this level. Basically, it is similar to the second level but the focus is different. System-wide level focus on the policies, structures and community wide resources needed for the implementation of long term changes. WHO’s innovative care for Chronic Conditions Framework, focuses more on the policies and community aspect. Furthermore, other system wide policy approaches are the ecological or public health model for chronic diseases. Population wide policies, community activities and health services are important as principles. 

In conclusion, in order to make the chronic disease management to be effective, we need to learn from the other countries. Even though, Indonesia is one of developing countries, early policies approach can lead to a better management in chronic disease. As I mentioned above, the other considerations such as cultural and accessibility factors, needs to be taken into account when formulating and stipulating the new policy. 

Reference:
1. Singh, D. How can chronic disease management programmes operate across care settings and providers. WHO Regional Office for Europe and European Observatory on Health System and Policies. 2008. 

Cycle ......

       Disaster is a condition that needs external resources to cope with the impact of the hazards occurs in an area. For this post, I would explain more about disaster but I will focus more on the disaster management cycles. Other than that, I would also describe some information related to two countries, Malaysia and Indonesia in the management of disaster in both countries. Before we proceed further, it is good for us to know the definition of the disaster management. Disaster management is the sum total of all activities, programmes and measures that are carried out before, during and after disaster in order to avoid a disaster, reduce its impact or recover from its losses. I believe that for each country in the world, the management of disaster is one of the important elements to be taken into account in government. Malaysia has its own organization that is responsible for the management of the disaster. This organization is known as Malaysian Centre for Remote Sensing (MACRES). Indonesia with ten times number of citizens in the country compared with Malaysia formulated three levels organizations for its country. These include BAKORNAS PB, SATKORLAK PB and SATLAK PB. I would explain more later in this chapter.

   Basically, for each disaster, there is one cycle that consists of three stages that need different kind of management. The first stage is pre-disaster stage. In this stage, a lot of measures can be taken in order to reduce human and properties losses such as carry out campaign to increase the awareness of population regarding the hazards, strengthening the existing weak structures and preparation of disaster management at individuals and community levels. Two important activities are always taken into consideration in this stage that is preparedness and mitigation. The former concerns about the rapid response of government, community and individual to disaster situation. Some of the examples related to preparedness are formulation of viable emergency system, the development of the warning system and maintenance of inventories and the trained personnel. The latter is related to the intervention for the reduction of the impact of hazards and the vulnerability. In order to perform this, we can either focus on hazards or the elements that are vulnerable to threats. Some interventions such as the storage of the water in drought prone area and relocating people living in hazards prone area to the temporary centre when the risk to be affected increased can be done. Malaysia under MACRES has established MACRES Ground Receiving Station in Temerloh, Pahang, that are able to receive downlink from SPOT-2, 4, 5, RADARSAT, NOAA, MODIS, and OCM. The role of MACRES is to disseminate info, provide early warning as well as establish disaster management system.

   Second stage is the stage of during disaster and the organizations in charge must make sure that the people needs and provisions are met and the suffering is minimized. It can take place at many locations such as damaged area, pre hospital area as well as hospital area. In pre-hospital setting, several measures can be carried out such as triage, resuscitation, stabilization, and transportation. 

 

   The third stage involves the response and recovery activities to achieve early recovery and rehabilitation of the community. As I mentioned above, Indonesia has its own mechanism in handling disaster through three main organizations. The first one is BAKORNAS PB that is chaired by Vice President and is a national coordinating board for disaster management. The functions of BAKORNAS PB are as policy makers, coordinate the implementation and monitoring the activities in disaster management, as well as rendering guidelines and direction for disaster management. SATKORLAK PB is a provincial coordinating unit for disaster management and SATLAK PB work as a implementation unit at districts or municipals level. The former is chaired by Governor and the later is chaired by Bupati or Mayor of the city. Indonesia has been using satellite as well for the management of disaster.

      In conclusion, even though each country has its own hazards but the management are slightly similar that focus on the immediate action taken in order to reduce the impact and increase the pace of recovery process. Learning form experiences and other countries can be used as one of the methods for the improvement of quality, effectiveness and efficiency of disaster management.

References:

1. Vihar, P. Delhi, 2006.  Natural Hazards and Disaster Management. Introduction to disaster management. Disaster management cycles.

2. BAKORNAS PB.  [online accessed on November 23rd 2010]

URL: http://www.aprsaf.org/data/aprsaf13_data/2_1_INDONESIA DM_1515day1.pdf

3. Hashim, M. National Disaster and Remote Sensing in Malaysia. [online accessed on November 23rd
 2010]

URL: www.aprsaf.org/data/jptm2_pdf/JPTM200606_12.pdf

4. Hendro Wartatmo. Medical Emergency Response.

Unpredictable Situation

                                                                     (booklyn.org) 
 Disaster as I mentioned and explained in previous post is something that cannot be predicted in some cases. This is true for the tsunami that hit Thailand in December 26, 2004. No one expected that earthquake with 9.0 Richter scale in Aceh would result in an estimated 5,395 death 8,500 injured people in Thailand. In my discussion below, I would emphasize more on the forensic management in Thailand specifically and not related to other countries affected by this mass disaster. Before we go further, I would like to give definition of mass disaster. Mass disaster is the disaster that killed 12 or more people in a single event.

In mass disaster, forensic team plays a very important role in the management of dead body. In Thailand’s tsunami situation, only the identification of the dead body was focussed instead of general purpose of forensic investigation that include the identification of the victim, the time and location, cause and the manner of death.

Basically, dead bodies scattered in tsunami affected area must be recovered soon before it undergo decomposition. Decomposition would make the forensic identification become more difficult. According to my lecturer, Dr. Yudha, there can be primary such as dental or secondary methods for identification. In this case, there were four major identification methods used that are dental (85.5%), fingerprints (12.6%), DNA (0.4%) and physical (1.2%). The physical method is less accurate when the duration taken for investigation was prolonged because of decomposition and the refrigerator available for dead body storage was not sufficient. This is different for Thai citizen. For Thai citizen, dental method contributed about 55% for the investigation, whilst fingerprints contributed around 39% but was getting increased due to the increased in ante mortem fingerprints data from family members of the victims. The DNA method used DNA sample from buccal mucosa, hair, and muscle tissues before decomposition but after that period the sample taken from tooth, femur and rib were more useful.

The dead bodies in this disaster were managed by some organizations as mentioned below:
a. Department of Disaster Prevention and Mitigation of Ministry of Interior.
b. Royal Thai Police.
c. Forensic science Institute, Ministry of Justice.
d. Universities.
e. Military.
f. Local Government.
- Helped in identification and released of the bodies to the family members of the victims.
g. Public health personnel.
- provide additional equipments and supplies.
h. Non-government organizations.
i. Ministry of Public Health
- provide the equipments and supplies
j. Other volunteers.
- Helped in transferring the bodies, numbering and tagging, cleaning of the bodies.


Even though these elements collaborated each other but the Department of Disaster Prevention and Mitigation of Ministry of Interior had taken the responsibility and provided the guidelines for dead body management and ordered the Royal Thai Police to consolidate the identification. TTVI that stand for Thai Tsunami Victim Identification was established later when the Royal Thai government realized the bodies were getting more decomposed. This situation need more experienced expert in handling this. So TTVI was the solution formed under Thai authority that allowed international collaboration to provide equitable treatment of the bodies.

In conclusion, the management of the mass disaster like tsunami really need proper guidelines and immediate action taken in order to make it cost-effective and increase the pace of the management.

References:
1. Sribanditmongkol, P. Et al. Forensic aspect of disaster casualty management
Tsunami Victim Identification in Thailand [online accessed on November 22th 2010]

URL: http://www.who.int/hac/events/tsunamiconf/presentations/2_16_forensic_pongruk_doc.pdf

Disaster?

This post is related to one of my block topics and to our latest disaster that hit my second home, Yogyakarta that started on 26th of October, 2010 and peaked on 5th of November, 2010. In this post, I would like to give a piece of information that hopefully, will help us understand about the concept of disaster.

Disaster? What is the meaning of disaster actually? If earthquake occur in the island in which there is no people and does not radiate (in term of vibration) to the other uninhabited area, it is considered disaster? Disaster word is originated from old French word, disastre. This word is a combination from the word Dis (bad or evil) and the word aster (star). The meaning of disaster is “A serious disruption in the functioning of the community or a society causing wide spread material, economic, social or environmental losses which exceed the ability of the affected society to cope using its own resources”.

There are four elements to be mentioned here; hazard, risk, capacity and vulnerability.

The hazards
Hazard is a dangerous condition or event, that threat or has potential of causing injury to life or damage to property or the environment. Hazard can be divided into natural, manmade or combination of both. The natural hazards such as earthquake or volcano eruption occur because of natural phenomenon. The manmade hazards such as wars, civil strikes or pollutions occur due to human negligence. Floods occur due to combination of both. We can take Merapi eruption as an example. If the human does not manage the path of the lava properly, it can lead to flood.

The Vulnerability
Vulnerability is the Extends to which a community, structure, service, or geographic area is likely to be damaged or disrupted by the impact of particular hazards, on account of their nature, construction and proximity to hazardous terrains or a disaster prone area.

Two categories of vulnerability; physical and socio-economic. The physical vulnerability is the related to “who” or “what” questions in term people or things that may be destroyed or damaged by natural disaster. Socio-economic vulnerability is related to the degree to which the population is affected by hazards not only in term of physical but socio-economic status as well. There were many people that were evacuated during Merapi eruption 2010, have been living in depressed state because they are not really strong in term of economy. Most of them who were living nearby Merapi volcano lost their properties such as house and their crops and poultry to which they depend on.

The capacity:
Capacity can be defined as “resources, means and strengths which exist in households and communities and which enable them to cope with, withstand, prepare for, prevent, mitigate or quickly recover from a disaster”.

Capacity can also be divided into two:
a. Physical.
b. socio-economic.

The physical capacity is related to human power to save things from their destroyed houses or from their farms and their ability to live in other area due to the skills or ability they posses to survive.

The socio-economic status is related to recover from disaster. Poor people suffer the most in most of the cases.

The risk:
Risk is a “measure of the expected losses due to a hazard event occurring in a given area over a specific time period.  The level of risk depends on three elements; nature of the hazards, vulnerability of the elements which are affected, and economic value of those elements.

References:
1. Vihar, P. Delhi, 2006.  Natural Hazards and Disaster Management. Introduction to disaster management.
[online accessed on November 19th  2010]

URL:
www.cbse.nic.in/natural%20hazards%20&%20disaster%20management.pdf

Incurable Disease

HIV/AIDS has become one of the major problems globally for decades. This problem does not only affect the health of carrier in poor and developing countries, but also affect people in developed countries. Once infected, there is no other way to reverse the condition. So, it is important for us to take some massive measures to prevent the spread of the disease in the population.

A piece of information about HIV/AIDS ....

History.

The reveal of AIDS was first recognized in summer 1981 when five previously healthy homosexual men with Pneumocystis jiroveci pneumonia in Los Angeles and 26 previously healthy homosexual men with Kaposi’s sarcoma with or without P. Jiroveci in Los Angeles and New York were detected. These cases were followed by the detection in female and male injected drugs users, in blood transfusion recipients, and in haemophiliacs.


Group at Risk (High):

 1. Injected Drug Users.

2. Heterosexual contact.

3. Male-to-male sexual contact.

My focus on this topic:

Circumcision is thought to reduce the risk of HIV transmission from women to circumcised men. This fact is supported by three randomized controlled trials that were carried out to examine the impact of male circumcision on HIV transmission. Three countries were involved in this studies; South Africa, Uganda and Kenya. In Orange Farm, South Africa, 3274 uncircumcised, HIV-negative men, aged between 18-24 years old were enrolled. The result showed 61% protective effect against HIV acquisition (Auvert et al., 2005). In Kisumu, Kenya and Rakai District, Uganda, 2784 and 4996 HIV-negative candidates respectively were enrolled. The results showed HIV acquisition was reduced by 53% in Kisumu and 51% in Rakai District.

The studies above showed that the circumcision can be used as one of the effective method for risk reduction of HIV transmission. Other preventive measures such as the correct and consistent use of condom, delay sexual debut, reduced numbers of sexual partners, avoidance of penetrative sex and voluntary HIV testing and counselling must be sustained. 

In order to make sure that this procedure is scientifically and medically appropriate, clinical guidelines must be issued by the State as a compulsory regulation for circumcision procedure. This is important based on the data in one of the province in South Africa. In 1995, this province stated more than 40 deaths, 40 mutilations, and more than 1000 hospital admission due to traditional circumcision.

A piece of info...

All men undergoing male circumcision should be clearly instructed and supported to abstain from sexual intercourse until certified that their wound has healed, normally taking up to six weeks, to avoid increasing the risk of both acquiring and transmitting HIV.





References:
1. WHO, 2008.Safe, voluntary, informed male circumcision and comprehensive HIV prevention programming. [online accessed on November 15th  2010]

URL: http://www.who.int/hiv/pub/malecircumcision/guide_decision/en/index.html

2. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.