TRAVEL MEDICINE

KLINIK DAN
AMBULANS
MOBILISASI DAN
EVAKUASI

INTRODUCTIONS TO TRAVEL MEDICINE

Despite the risk of emerging and re-emerging

infectious diseases and the threat of terrorism

,international ,tourist arrivals remain high,as
does travel from industrialized to developing
countries
Travel medicine is the discipline devoted to
the maintenance of the health of internasional
travelers through health promotion and
disease prevention

 The global focus and knowladge base of

travel medicine distinguishes this unique

specialty from other fields of medicine and
nursing
There is a need for improvement in the
evidence base in travel medicine in order to
provide the most accurate pre-travel health
advice

Travel health risks vary greatly according to

where
versus

industrialized
developing countries

city or highly developed

resort versus off-thetourist-trail

When
dry
How long

season of travel ,rainy

versus

duration of stay abroad

what for
tourism versus businnes
versus rural work versus
visiting friends or relative
other
(military,airlaine crew
layover,Adoption
,etc)

How (travel characteristics)

hygiene standart expected :high
versus low (low budget backpackers )
Special activities :high altitude
trekking,diving,hunting ,camping ,etc

host characteristic
healthy versus pre-existing
condition ,non immune versus
(semi)immune
age, infants ,senor
travelers

Starting organizing marketing a

travel clinic

Introduction
Travel clinics that travelers can receive up-to-

date advice on avoiding travel related illnes

the care of any chronic medical conditions and
receive required or recommended
immunizations for their trip
Why should the traveling plubic visit a travel
clinic ?the publication of this and other
texbooks and journals devoted entirely to the
field of travel medicine supports the premise
that travel medice has a defined area of
expertise and knowledge

 There are sufficient risks to the traveler such

as traveler`s diarrhea ,life threatining

malaria ,vaccine preventable disease and
accidents and injuries that establish the point
that all travelers should receive educations
and conseling prior to their trips
What are the advantages of visisting a travel
medicine specialist rather than generalist ?
some of the reason are detailed in table 3.1

THE PRACTICE OF TRAVEL

MEDICINE
In the UK most pre-travel care is rendered in General

Practice and the practice nurse is usually the sole

provider ,giving advice under the direction of specific
protocols .
In the ISTM survey most physician (63%) had trained
in infectious desease or tropical medicine
Where are travelers going Data from the world Tourism
Organization indicate that for the 842 million
international arrivals during the year 2006 Europe was
the most frequent destination (54.5%) conversely ,for
travelers who visited a travel medicine service in
connecticut over a 19-year time period (1984-2002)

ELEMENTS OF A TRAVEL MEDICINE

PRACTICE
Canadian Committe to advise on tropical

medicine and travel (CATMAT) and the

infectious disease society of america (IDSA) In
their respective guidelines on the practice of
travel medicine
Key elements of the travel health encounter
are risk assessment of the traveler and their
trip provision of advice about prevention and
management of travel related disease (both
infectious and non infectious )

 In the UK a diploma (year-long course )or

masterslevel degree in travel medicine can be

obtained
The american society of tropical medicine and
hygiene (ASTM&H) has also developed an
examination leading to a certificate of knowledge
that focuses primarily on tropical medicine
Most expert agree that is not neceessary for travel
medicine providers to have expertise in tropical
medecine
The most common conditions in ill-returned
travelers

 In order to maintain competency some expert

recommend that 10-20 pre travel

consultations be performed per week
Member ship of the ISTM should be considered

PERSONNEL AND MODELS OF CARE

Most practices of travel medicine have both

physicians and nurses participating in the care of

patients.
For clinics in which both physician and nurses
provide care there are two general models (as
outlined in fig 3.2)
In the UK this model of independent care rendered
by nurses is supported by a legal framework
known as patient group directions (PGD)
The PGD requires that the nurse receive
appropiate training updating and audit of practice

RISK ASSESSMENT OF THE

TRAVELERS
THE MEDICAL RECORD
The key feature of the provider traveler
encaunter is a risk assessment that allows the
advice and intervention to be individually
matched to the traveler
The risk assessment of the traveler includes
who the traveler is (demographics and any
medical conditions that might affect travel or
prophylactic measures )and what type of
health risks may be exposed to during their
trip

 After recording the traveler`s demographics

,itinerary,travel activities and medical history ,an

immunization history should be obtained
Because the pre-travel visit is an ideal time to
update recommended childhood,adolescent,or
adult vaccines the provider needs to determine
and record the dates of these vaccine
Elements required by law in the USA include
vaccine type ,dose date of administration
,manufacturer and lot number ,site of
administration and name and title of administrator

 In the USA the methods and forms for reporting

adverse events can be obtained by calling 1-800822-7967 or accessing http

www.fda.gov/cber/vaers/vaers.htm and
downloading the form
The division of immunization in canada has a
similar reporting system and can be reached by
calling 1-613-954-5590
In the UK suspected adverse event report are made
to the medicines healthcare ,product regulatory
agency through the ` yellow card scheme`

INFORMATION AND RESOURCE

FOR THE TRAVEL MEDICINE SPECIALIST
Health information for international travel
(known as the `yellow book`) for the US
provider
This has moved travel medicine to a speciality
that can respond on a daily basis to changes
in the epidemiology
Practicing travel medicine without the use of
these resource leads to a decreased level of
service

 Specialized travel clinics wil likely use both

country developed and international resource

The ASTM&ISTM listservs require membership
in the organization
Promed mail a program of the international
society for infectious disease is a moderated
global electronic reporting system for
outbreak of emerging infectious disease

 Each clinic should decide how these resource

are put into practice to help standardize the

care
How ever ,the situation should not arise that
travelers who are going on the same trip (and
presumably describe the trip similarly) and
have the same medical circumstances
But who come into the clinic at different time
and are seen by different providers receive
different advice ,vaccines and medication

 To avoid this situation ,specific protocols for

each country visited can be used

The indication and schedules for immunization
and the standards for malaria
chemoprophylaxis it is necessary to match
any protocols to the practice standart of the
region,province,or country in which the travel
clinic is located
In addition ,it should always be remembered
that prophylaxis recommendations as another
to thailand

FOR THE TRAVELER

Education is the mainstay of pre-travel health
care
Airport surveys of travelers departing to regions
considered at risk for malaria and/or vaccine
preventable disease document that despite
travelers having some knowledge of these
desease
Therefore most travel health advisors recommend
providing the traveler with written materials that
summarize and highlight the information

 Therefore most travel health advisors recommend

providing the traveler with written materials that

summarize and highlight the information
In the survey of travel medicine clinics written
advice on malaria was provided 94% of the time
,information on insect avoidance 86% of the time
and information on traveler`s diarrhea 91% of the
time
Booklet and monographs can deal with a wider
range of topics and can be purchased separately
by the traveler

 It is important ,however that written advice on

the key medical and health issues is included

as part of the visit and is not an optional extra
expense item

POLICIES AND PROCEDURES

Vaccine information statement (VIS) on each

vaccine given for routine healthcare in the

USA as well as for many travel realated
vaccine
These may be downloaded from the CDC at
www.cdc.gov/vaccines/pubs/vis
The VIS for measles ,mumps,rubella vaccine is
reproduced infigure 3.4
The clinic should write its own information
statement

EQUIPMENT
A refrigerator and freezer are required for

vaccines ,vaccine storage should be their sole

use
Vaccine requiring refrigeration should be
maintained at 2-8 C (35-46 F) with an optimal
temperature of 5 C (40 F)
Vaccines that require frozen stirage should be
maintaned at -15 C (5 F) or cooler with an
optimal temperature of -20 C(0 F)

ADDITIONAL TRAVEL CLINIC

SERVICE
Most clinic are willing to provide it to the

general public
Clinic that have agreements with
businesses ,non governmental organizations
(NGOs ),or school and universities may choose
to provide e-mail advice for their clients
The travel clinic survey found that 16% of
clinics charged for this advice

 If the clinic chooses to provide telephone or e-

mail advice, it should be clear who will

respond to the requests and when the
response will be made
The advice given should be from standard
protocols
A method should also be developed that
records both the query and the advice given
For telephone calls a standart form should be
completed during the call

 Additioanlly a clinic that handles many

telephone request may wish to develop a

voice recording system
A clinic will need to decide how detailed to
make their advice
Giving general rather than specific advice to
public inquiries may be best and because the
clinic has not established a formal physician
patient relationship it may also be the safest
course from a medico legal point of view

 In some clinic (usually outside of the USA ) pre-

packaged antimalarial drugs standby treatment

drugs for traveler`s diarrhea or malaria and
drug to prevent acute mountain sickness can be
sold to travelers during the consultation
The consensus statement on travel medicine by
canadian travel medicine experts the IDSA as
well as the body of knowledge developed by the
ISTM does not require an extensive knowledge
of tropical disease by travel medicine specialist

 Therefore all travel medicine specialist should

be able to recognize key syndromes in the

returned traveler and know how to refer them
for adequate care
These key syndromes include fever ,skin
disorders acute and chronic diarrhea and
respiratory complaints
Clinics with contract with businesses ,NGOs or
education institution may provide health
advice for ill clients during their trips

 The combination of a travel clinic and a

vaccine clinic is a natural association

Vaccine clinics can immunize immigrants who
need immunizations to obtains entyr visas
In some cases such as with immigrants or
veterinarians it is necessary to use laboratory
service to check serolgy for proof of immunity
to measles or varicella ,as examples or
whether the titer of rabies antibody in
previously immunized person

 Vasccine clinic visits are of short duration and

efficient and lead to increased productivity of

the clinic

FEES AND REVENUE FOR A TRAVEL

MEDICINE PRACTICE

In the USA ,travel clinics range from being

entirely private ,fee-for-service facilities in
which the providers do not join any third
party carrier plans ,to hospital or medical
school based clinics in which fees are set by
the hospital or university practice plan and
all providers participate with insurance
programs

 In a study of travelers from Hongkong ,older

age ,the frequency of previous travel an

ability to assess travel health risk ,exercising
precautionary behavior on prior trips and
exposure to health protection materials
,correlated with a willing ness to pay for travel
medicine service
Medicare will cover routinely recommended
vaccines for adults :influenza,pneumococcal
,tetanus,hepatitis B

 Most patients will require a referral from their

primary care physician in order for the clinic

to bill the patient`s insurances company
Most reimbursable care in travel medicine
consists of a consultation fee,vaccine fees and
vaccine administration charges
Providers in some countries may also charge
for writing prescription

 The correct billing codes should be applied to

each of these services in the USA both a

diagnostic code called an ICD-9 code
(international classification of deseas)

PASSENGER HEALTH
The passenger with certain pre-existing

conditions the cabin environment may

exarcerbate their underlying problems
The complex airport environment can be
stressful and challenging to the passanger
,leading to problems before even becoming
air-bone
Disabled pasengers do need to notify the
requirement for special need such as
wheelchair assistance or assignment of seats
with lifting armrests and this should be done
at the time of booking

Pre flight assessment and medical

clearance
Most major airlines provide service for those passengers

who require extra help and most have a medical advisor

to asses the fitness for travel of those with medical needs
Copies of the Asma Guidelines may be obtained from the
Association online at www.asma.org or tel 7037392240
The International Air transport association (IATA) publishes
a recommended medical information from (MEDIF) for use
by member airlines
The MEDIF should be completed by the passenger`s
medical attendant and passed to the airline or travel
agent at the time of booking to ensure timely medical
clearance

Medical clearance is required when special service are

required (oxygen,stretcher or authority to carry or use

accompanying medical equipment such as ventilator or a
nebulizer
It is vital that passanger remember to carry with them any
essential medication and not pack it in their checked baggage
Deterioration on holiday or an a bussines trip of a previously
stable condition such as asma ,diabetes,or seizure disorders
can often give rise to the need for medical clearance for the
return journey
It is important for all travelers to considers supplemental
travel insurance which include provision for the use of a
specialist repatriation company to provide the necessary
medical support

Assesment criteria
A basic knowledge of aviation physiology and

physics can be applied

Any trapped gas will expand in volume by up to
30% during flight and consideration must be given
to the effect of the relative hypoxia encountered at
a cabin altitude of up to 8000 ft above mean sea
level
The passenger`s exercise tolerance can provide a
useful guide on fitness to fly
More spesific guidance can be gained from
knowledge of the passenger`s baseline sea level
blood gas levels and hemoglobin value

A good source of guidance is provided by the British

thoracic society website

The guidelines recommended by one international
carier
The prolonged period of immobility associated with
long-haulflying can be a risk for those individuals
predisposed to develop deep venous thrombosis (DVT)
Pre-existing risk factors include
Blood disorders and cloting factor abnormalities
Cardiovascular desease
Malignancy

Major surgery
Lower limb /abdominal trauma
DVT history
Pregnancy
Estrogen therapy (including oral contraception and

hormone replacement therapy)

>40 years of age
Immobilization
Pathological body fluid depletion
Smoking
Obesity
Varicose veins

Those passengers known to be vulnerable to

DVT should seek guidance from their

attending physician on the use of compression
stockings and /or anti-coagulans
There is currently no evidence that flying
perse is a risk factor for the development of
DVT but those at high risk should avoid any
from of prolonged immobilization such as is
associated with travel

Considerations of physical disability

or immobility
In addition to the reduction in ambient

pressureand the relative hypoxia it is

important to consider the physical constrain of
the passengers cabin
A passenger with a disability must not impede
the free egress of the cabin occupants in case
of emergency evacuation
There is limitedleg space in an economy class
seat and a passenger with an above knee leg
plaster or an ankylosed knee or hip may
simply not fit in the available space

The long period of immobility in an

uncomfortable position must be taken into

account and it is imperative to ensure
adequate pain control for the duration of the
journey
To avoid impeding emergency egress
immobilized or disabled passengers cannot be
seated adjacent to emergency exits
A plastered leg cannot be stretched into the
aisle because of the conflict with safety
regulations

Oxygen
In additions to the main gaseous system all

comercial aircraft carry an emergency oxygen

supply for use in the event of failure of the
pressurization system
The drop down masks are automitically released en
masse (the socalled `rubber jungle `)in the event of
the cabin altitude exceeding a pre-determined level
of between 10.000 and 14 000
This passengers emergency supply has a limited
duration if provided by chemical generators ,usually
in the region of 10 min

The flow rate is between 4 and 8L (NTP) /min and is

continous once the supply is triggered by the passenger

pulling on the connecting tube
Sufficient first aid oxygen bottles are carried to allow the
delivery of oxygen to a passenger in case of a medical
emergency in-flight ,at a rate of 2 or 4 l (NTP) /min .
This cannot be used to provide a pre meditated supply for
a passanger requring it continously troughout a journey
If a passenger has a condition requiring continous
(scheduled )oxygen for journey This needs prenotification to the airline at the time of booking the ticket

Oxygen bottles regulators and masks must

meet minimum safety standart set by the

regulatory authorites and the oxygen must be
of `aviation`quality` which is a higher
specification than medical quality

In-flight medical emergencies

An in flight medical emergency is defined as a medical

occurrence requiring the assistance of the cabin crew

One major international airline recently reported 3022
incidents occuring in something over 34 million
passenger carried in 1 year
The breakdown of these incidents into generalized
causes is shown 46.2
The top six flight emergency medical condition
reported by the same airline are shown in table 46.3
Any acute medical condition occuring during the course
of a flight can be alarming for the passenger and crew
because of the remoteness of the evironment

Cabin crew members receive training in

advanced first aid and basic life support and

the use of the emergency medical equipment
carried on board the air craft

Good samaritans
In serious cases they may request assistance from a

medical professional traveling as a passenger

It is statutory requirement for a medical
professional to offer assistance to a sick or injured
person
Some countries (USA) have enacted a good
samaritan law whereby an assisting professional
delivering enmergency medical care within the
bounds of his or her competent
In the UK the major medical defense insurances
companies provide indemnity for their members
acting as good samaritans

Some airlines provide full idemnity for medical

professional assisting in response to a request from

the crew
Recognition by the airline of the assistance given by
the good samaritan is complicated by the special
nature of the relationship between the professional
the patient and the air line
Follow up of the outcome for the passenger after
disembarkation is frequently difficult because the
sick passenger is no longer in the care of the airline
and become the responsibilty of the receiving
hospital or medical practitioner

Aircraft medical diversion

Responsibility for the conduct of the flight

rests with the aircraft captain who makes the

final decision as to wheter or not an
immediate unscheduled landing or diversion is
required for the well being of a sick passenger
The captain has to take into account
operational factors as well as the medical
conditions 0f the sick passenger

Telemedicine
Satcom is installed in newer long range

aircraft and is gradually replacing HF as the

industry norm for long range communications
Pulse oximetry and ECG are examples of data
that can assist the medical advisor to give
appropiate advice to the aircraft captain

Resuscitation equipment
CPR techniques are an essential part of cabin

crew training
Equipment with AEDs and for the cabin crew
to be trained in their use
This has been mandated in the USA bt the FAA
Experience of those airlines which carry AEDs
indicates that there may be benefits to the
airlines operation as well as to the passenger

Conclusion
The pressurized aircraft cabin provides

protection againts the hostile environment

encountered at cruising altitudes

It is important for medical professionals to be

aware of the relevant factors and un realistic

public expactations to be avoided
Transmission abroad aircraft of illnesses such
as tubercolosis ,SARS and other respiratory
desease has ben reported but is infrequently
documented and probably rare
Most air lines have a medical advisor who may
be consulted before flight to discussthe
implications for a particular passenger

Alterations of cardiovascular
function
Today the focus is on the genetic

neurohumoral and inflammatory mechanisms

that underlie tissue and cellular processes
such as endothelial injury remodeling,
stunning ,reperfusion injury and autoimmune
disease

Diseases of the veins

VARICOSE VEINS AND CHRONIC VENOUS
INSUFFICIENCY
A varicose vein is a vein in which blood has pooled
Varicose vein typically involve the saphenous veins of
the legs and are distended tortous and palpable
Are caused by trauma to the saphenous veins that
damages one or more valves ,gradual venous distention
caused by the actions of gravity on blood in the legs
Veins are thin-walled ,highly distensible vessels
Normally the muscular pump in the legs moves venous
blood up toward the heart and valves prevent backflow
and pooling of blood

 In individuals who habitually stand for long periods

wear constricting garments or cross the legs at the

knee distention progresses until the pressure in the
vein damages venous valves rendering the valves
incompetent
Varicose veins and valvular incompetence can
progress to chronic venous insufficiency (CVI)
CVI is inadequate venous return over a long period .
Venous hypertension circulatory stasis and tissue
hypoxia lead to an inflammatory reaction in vessels
and tissue leading to fibrosclerotic remodeling of the
skin and then to ulceration

Symptoms include chronic pooling of blood in the

veins of the lower extremities and

hyperpigmentation of the skin of the feet and ankles
Infection can occur because poor circulation impairs
the delivery of the cell and biochemicals for the
immune and inflammatory responses
Varicose veins and CVI may be associated with deep
venous thrombosis (in a deep vein DVT ) in some
individuals because of changes in collateral flow and
shared risk factors therefore anyone with new onset
varicose veins should be evaluated for the possibility
of underlying DVT

 Treatment of varicose veins and CVI begins

conservatively
THROMBUS FORMATION IN VEINS
A trombus is a blood clot that reamins
attached to a vesel wall
A detached thrombus is a thromboembolus
Venous thrombi are more common than
arterial thrombi because flow and pressure are
lower in the veins than in the arteries

 DVT occurs primarily in the lower extremity

three factors (triad of virchow ) promote

venous thrombosis 1. venous stasis
(immobility,obesity,prolonged leg dependency
)(air travel ) age ,congestive heart failure
(CHF)
2. venous endothelial damage (trauma
medications)
3. hypercoagulable states (inherited disorders
malignancy,pregnancy,oral
contaceptives,hormone replacement
hyperhomocysteinemia,antiphospholipid
syndrome)

THE EXPEDITION MEDECINE

INTRUDUCTION
A uniting theme is that expeditions will usually visit areas of

climatic extremes (mountains,polar regions,desert, the tropical

jungle or the ocean )and that they will undertake some kind of
activity ,whether this be scientific research or an adventure
activity such as climbing,kayaking,rafting,daving caving or
sailing
Expedition doctors are rarely paid to accompany such as group
In fact many expeditions leave with no physician or other
medical provider here is another opportunity for travel
medicine outreach and education
The aim of the expedition doctor is to minimaze risk by taking
sensible precautions advising on the correct pre-travel
preparation ,managing potential environmental risk and being
as prepared as possible to manage emergencies that may arise

QUESTIONS TO ASK
The opportunity to be trip physician may come as

an unexpected phone call or e-mail ,or at other

times the expedition physician may be founding
member of the expeditionary team
Strong communication abilities ,interpersonal
skill,and sensitivity are all vital components for all
members of the expedition leadership physician
included
Even then, medical action (once the patient has
been medically stabilized )should take place in a
coordinated fashion with all team members aware
of and agreeing on the plan

Before ,during and after the trip what are the

physician responsibilities to the programs ?

PERSONAL PREPARATION
It is important for the trip physician to be prepared

to handle almost any emergency that may occour

A background combining primary care,emergency
medicine and tropical or travel medicine would be
ideal
The physician is adequately equipment before the
expedition is undertaken
basic resuscitation skills on an emergency life
support (ELS) advanced cardiac life support (ACLS)
or acute trauma life support (ATLS) course should
be renewed or taken up

 Management of chronic disease exacerbahation

(CHF,CAD,asma and diabetes) should be reviewed

Comfortable with SAM, splint (or equivalent) to
improvise immobilization for common orthopedic
conditions including fractures
Familiarity with shoulder ankle,and elbow dislocation
management
Comfortable with the use of sport tape to treat
common sprains and strains
Knowledge of basic dental skill using cavit for
temporary fillings
Management of epistaxis

 Proficiency with wound care including

laceration burns and foreign bodies

Comfortable with dealing with minor
opthalmological problems such as corneal
foreign body corneal abrasion
Knowledge of the use of basic transportation
and evacuation system
Environmental extremes of heat cold
,humidity altitude depth UV exposure or
motion all have their consequent medical
problems

REPATRIATION
Pre-existing illnes clauses should be looked for

and addressed if appropriate

When does he or she leave the patient to
rejoin the groups for which he or she
continues to have overall medical
responsibility ? This is a complicated question
depending on many variables and should be
discussed with expedition leadership as soon
as posible

DEATH OVERSEAS
Westren physician may be surprised to find a

system where medication and supplies need

to be purchased (cash only) at a pharmacy
and then provided to the local doctors for use
It is important for the expedition physician to
be aware of these potential issues when
coordinating local medical care for the group.
Repatration of remains is usually arranged by
the appropiate local embassy or consulate

Medical evacuation
Medical evacuation, often termed Medevac

or Medivac, is the timely and efficient

movement and en route care provided by
medical personnel to wounded being
evacuated from a battlefield, to injured
patients being evacuated from the scene of an
accident to receiving medical facilities, or to
patients at a rural hospital requiring urgent
care at a better-equipped facility using
medically equipped ground vehicles (
ambulances) or aircraft (air ambulances).

Examples include civilian EMS vehicles,

civilian aeromedical helicopter services, and

Army air ambulances. This term also covers
the transfer of patients from the battlefield to
a treatment facility or from one treatment
facility to another by medical personnel, such
as from a local hospital to a trauma center.

USAF Sikorsky R-5 Helicopter evacuates casualties during the Korean War

The term medevac is commonly applied to a

motor vehicle, fixed-wing aircraft, or helicopter used as

an ambulance (sometimes called an "air ambulance") to
provide medical care in route. This permits the rapid
transport of seriously injured persons, particularly
trauma patients, from the scene of the accident to the
hospital. News accounts of such transportation often use
the terms "airlifted" or "LifeFlighted", although medevac
is a common term used by civilians as well. Most
patients transported by medevac are taken to a
specialized hospital known as a trauma center. Medevac
can refer to either ground or air assets being utilized,
the use of this term can cause confusion. [citation needed]

The technique has its roots in the

establishment of the Australian

Royal Flying Doctor Service, which was
established in 1928 to bring doctors to
patients and patients to hospitals from the
remote outback. Inevitably, the immense
military potential of the practice was realized
with the development of the helicopter

Modes of evacuation on board

Ship-shore
If the medical situation of the patient allows and the

distance towards a shore-based medical facility is within

acceptable reach in distance and time, the safest and
most comfortable mode of evacuation is by the vessel
itself delivering the patient. This may imply that the
vessel changes its course/ itinerary towards a nearer
port than the one that was scheduled. Via the RCC or
the vessels shipping agent medical transportation on
land (usually an ) will need to be arranged separately
to transport the patient to a medical facility ashor

Ship-ship
If the above is not feasible, the vessel may arrange a

rendezvous with another vessel and transfer the patient. This

may have two different motives.
Most often the patient will be transferred onto a vessel serving
primarily for the transport to a medical facility ashore, these
boats being faster and more manoeuvrable than the vessel
itself. These boats, often of the all-weather type, are evidently
confined to coastal waters and have a range of a few tens of
nautical miles. They mostly have personnel on board with
medical training often equaling or surpassing that of the ships
crew, so they can be of help in stabilizing the patient before
transferring him onto the lifeboat. Pilots vessels or sometimes
shipping agents craft may be needed to transport a patient
ashore.

Sometimes the patient may be transported to

a vessel offering more advanced medical care.

Naval vessels, passenger cruise vessels and
hospital ships are some examples of ships
that will offer help in case of medical
emergencies, sometimes far out at sea. These
different options will be described in more
detail further on.

Ambulans umumnya dilengkapi dengan 5 jenis suara

sirine, yaitu yelp, wail, phaser, hi-lo dan horn. Fungsi

dari jenis suara ini pun berbeda-beda. Wail
digunakan ketika kendaraan berjalan di jalur yang
lurus, yelp digunakan ketika kendaraan berada di
persimpangan, hi-lo digunakan sebagai kombinasi
untuk mendapatkan perhatian yang lebih efektif, dan
horn digunakan seperti klakson untuk memberikan
peringatan lebih jika suara-suara lainnya tidak
mendapat perhatian pengguna jalan lain.
| Bunyi Horn | | Bunyi Hi-lo | | Bunyi Phaser | |
Bunyi Yelp | | Bunyi Wail

Lambang palang enam berwarna biru yang terpampang

samping kanan-kiri mobil ambulans disebut star of life.

Diadopsi dari lambang American Medical Association (AMA),
lambang ini menggunakan palang enam yang kemudian
dipatenkan sebagai lambang EMS pada 1 Februari 1977. 6
palang biru mengambarkan 6 point fungsi dari emergency
medical services atau EMS yang dapat diuraikan sebagai
berikut:
1. Detection
2. Reporting
3. Response
4. On Scene Care
5. Care in Transit
6. Transfer to Definitive Care

Ambulans transport

Tujuan Penggunaan :
Pengangkutan penderita yang tidak memerlukan perawatan
khusus/ tindakan darurat untuk menyelamatkan nyawa dan
diperkirakan tidak akan timbul kegawatan selama dalam
perjalanan.
Petugas :
1 (satu) supir dengan kemampuan BHD (bantuan hidup dasar)
dan berkomunikasi
1 (satu) perawat dengan kemampuan PPGD (pertolongan
pertama gawat darurat)
Peralatan :
Tabung oksigen dengan peralatannya
Alat penghisap cairan/lendir 12 Volt DC
Peralatan medis PPGD (tensimeter dengan manset anakdewasa, dll)
Obat-obatan sederhana, cairan infus secukupnya

Ambulans gawat darurat

Tujuan Penggunaan :
Pertolongan penderita gawat darurat pra rumah sakit, pengangkutan
penderita gawat darurat yang sudah distabilkan dari lokasi kejadian ke
tempat tindakan definitif atau ke rumah sakit, sebagai kendaraan transport
rujukan.
Petugas :
1 (satu) pengemudi berkemampuan PPGD dan berkomunikasi
1 (satu) perawat berkemampuan PPGD
1 (satu) dokter berkemampuan PPGD atau ATLS/ACLS (advanced trauma
life support/advanced cardiac life support)
Peralatan :
Peralatan rescue :
Lemari obat dan peralatan
Tanda pengenal dari bahan pemantul sinar
Peta wilayah setempat
Persyaratan lain menurut perundangan yang berlaku
Lemari es/ freezer, atau kotak pendingin

Medis :

Tabung oksigen dengan peralatan bagi 2 orang

Peralatan medis PPGD
Alat resusitasi manual/automatic lengkap bagi dewasa dan anak/
bayi
Suction pump manual dan listrik 12 V DC
Peralatan monitor jantung dan nafas
Alat monitor dan diagnostik
Peralatan defibrilator untuk anak dan dewasa
Minor surgery set
Obat-obatan gawat darurat dan cairan infus secukupnya
Entonox atau gas anastesi
Kantung mayat
Sarung tangan disposable
Sepatu boot

Ambulans rumah sakit lapangan

Tujuan Penggunaan :
Merupakan gabungan beberapa ambulans gawat
darurat dan ambulans pelayanan medik bergerak.
Sehari-hari berfungsi sebagai ambulans gawat
darurat.
Petugas :
1 (satu) pengemudi berkemampuan PPGD dan
berkomunikasi
1 (satu) perawat berkemampuan PPGD atau
BTLS/BCLS (basictrauma life support/basic cardiac life
support)

1 (satu) dokter berkemampuan PPGD atau

ATLS/ACLS
Peralatan :
Peralatan rescue :
Lemari obat dan peralatan
Tanda pengenal dari bahan pemantul sinar
Peta wilayah setempat dan detailnya
Persyaratan lain menurut perundangan yang
berlaku
Lemari es/ freezer, atau kotak pendingin

Medis :

Tabung oksigen dengan peralatan bagi 2 orang

Peralatan medis PPGD
Alat resusitasi manual/automatic lengkap bagi dewasa dan anak/
bayi
Suction pump manual dan listrik 12 V DC
Peralatan monitor jantung dan nafas
Alat monitor dan diagnostik
Peralatan defibrilator untuk anak dan dewasa
Minor surgery set
Obat-obatan gawat darurat dan cairan infus secukupnya
Entonox atau gas anastesi
Kantung mayat
Sarung tangan disposable
Sepatu boot

 Ambulans pelayanan medik bergerak

Tujuan Penggunaan :
Melaksanakan salah satu upaya pelayanan medik di
lapangan. Digunakan sebagai ambulans transport.
Petugas :
1 (satu) pengemudi berkemampuan PPGD dan
berkomunikasiPerawat berkemampuan PPGD
dengan jumlah sesuai kebutuhan
Paramedis lain sesuai kebutuhan
Dokter berkemampuan PPGD atau ATLS/ACLS
Peralatan :

Peralatan rescue :

Peta wilayah setempat

Persyaratan lain menurut perundangan yang berlaku
Lemari es/ freezer, atau kotak pendingin.
Medis :
Tabung oksigen dengan peralatan
Peralatan medis PPGD
Alat resusitasi manual/automatic lengkap bagi dewasa dan
anak/ bayi
Suction pump manual dan listrik 12 V DC
Obat-obatan gawat darurat dan cairan infus secukupnya
Sarung tangan disposable
Sepatu boot

Small Emergency Transport Pack

Standart Minimal yang harus di persiapkan atau

di bawa ketika transport pasien:

Emergency Transport Pack; ini merupakan

peralatan yang terpenting karena berisi berbagai

macam obat dan peralatan intubation. Untuk
peralatan yang harus ada diantaranya peralatan
intubasi /intubation equipment yang berisi;
laryngoscope handle, blades size 3 & 4, ETT size 6, 7,
8 and 9, Magills forcep, KY jelly, stylet /introducer,
10ml syringe, long suction catheter, white tape,
Nasopharyngeal airways size 7 and 8 dan yang
terakhir 2 pairs of glove/sarung tangan. Sedangkan
untuk obat2 yang harus tersedia di pack termasuk;
suxamethonium x2 amps & 5 ml syringe, Recuronium
1x vial & 5 ml

Midazolam 20mg & 20 ml syringe, Propofol

20mg & 20 ml syringe, Aramine 2 amps & 20
ml syringe, Adrenaline minijet 2x, Atropine
minijet 2x and 10 ml saline amps x6.
Keperluan lain di antaranya Hydration stuff
seperti gelofusion x1 and blood pump set x1.
Dan yang paling terpenting emergency pack
ini harus di check setiap sehabis di pakai
untuk bisa di lengkapi ulang termasuk
pengecekan expired date. Dan minimal
pengecekan emergency pack ini satu kali tiap
shift.

Ambubag; ini merupakan peralatan penting untuk

memberikan bantuan pernafasan di saat pasien

gagal nafas dan ini harus di sambungkan ke
tabung oxigen kecil.
White pack; pack ini berisi mask size kecil,
sedang dan besar, juga berisi Oropharyngeal
Airway size small, medium and large.
Oxygen transport; Ini di lengkapi dengan suction
dan tabungnya. sedangkan untuk tabung
oxygennya bisa di gunakan tabung yang kecil
karena ini sifatnya hanya sementara atau emergen