STUDY GUIDE TRAVEL MEDICINE 13 okt 2017
Study Guide
Special Topics
Udayana University Faculty of Medicine, DME
1
Study Guide
Special Topics
TIME TABLE
TIME
Activity
PIC
Oct.13th – Oct 26th,2017 Learning Activity
Oct 27th ,2016
Preparation for final test
th
Oct 30 ,2016
Evaluation
Coordinator
Teams
MEMBERS TEAM
No
Name
1
dr. Made Agus Hendrayana, M.Ked (Coordinator)
2
3
5
6
7
Prof.DR.Dr. Tuti Parwati Merati, SpPD-KPTI
dr. I Ketut Agus Somia, SpPD-KPTI
dr. Anita Devi,M.Si
Dr.dr. Tjok Senapathi,Sp.An KAR
dr. I Made Ady wirawan,MPH,PhD
Department
Phone
Microbiology
08123921590
Internal medicine
Internal medicine
Hyperbaric
Anestesiologi
Public Health
08123806626
08123989353
081805505911
081337711220
081239394465
Department
Internal Medicine
Internal Medicine
Internal Medicine
Microbiology
Cardiology
Hyperbaric
Internal Medicine
Anestesiologi
Internal Medicine
Internal Medicine
Internal Medicine
Public Health
Fisiology
Phone
08123806626
08123989353
08123994203
08123921590
081330530247
081805505911
08123815025
081337711220
081338728421
08123803985
08123320380
081239394465
081999636899
LECTURERS
No
1
2
3
4
5
6
7
8
9
10
11
12
13
Name
Prof. DR. dr. Tuti Parwati Merati, SpPD-KPTI
dr. I Ketut Agus Somia, SpPD-KPTI
dr.i Gusti Ngurah Bagus Artana,Sp.PD
dr.Made Agus Hendrayana,M.Ked
dr. Luh Oliva Saraswati Suastika,Sp.JP
dr. Anita Devi,M.Si
dr. Made Susila Utama,Sp.PD-KPTI
Dr.dr. Tjok Senapathi,Sp.An KAR
DR.dr.Ketut Suega,Sp.PD-KHOM
dr.A.A.Yuli Gayatri,Sp.PD
dr. Ni Made Dewi Dian Sukmawati,Sp.PD
dr. I Made Ady wirawan,MPH,PhD
dr.I Putu Adiartha Griadhi,M.Fis
~ FACILITATORS ~
No
1
Name
dr. Ketut Sudiasa, Sp.B(K) Trauma
Udayana University Faculty of Medicine, DME
Group
Departement
A1
Surgery
Phone
08123811106
Venue
(3rd floor)
3rd floor:
R.3.09
2
Study Guide
Special Topics
2
3
4
5
6
7
8
9
10
Dr. dr. Tjok G.A Senapathi, Sp.An.
KAR
dr. Ni Made Dewi Dian Sukmawati,
Sp.PD
dr. Firman ParulianSitanggang,
Sp.Rad(K)RI
dr. I GstNgr. Wien Aryana, SpOT (K)
Dr.dr. IGAA Praharsini, SpKK,
FINSDV
Dr. Luh Made Indah Sri
HandariAdiputra, S.Psi., M.Erg
Dr.dr. AA. Mas Putrawati T., Sp.M(K)
dr. I Gede Budhi Setiawan,
Sp.B(K)Onk
dr. I Kadek Susila Surya Darma,
M.Biomed, Sp.JP, FIHA
081337711220
A2
Anestesiology
A3
Internal
Medicine
08123320380
A4
Radiology
081337165566
A5
Orthopaedi
0811385263
A6
Dermato
venerology
08123888794
A7
Fisiologi
081337095870
A8
Opthalmology
08123846995
A9
Surgery
08123923956
A10
Cardiology
08113853151
3rd floor:
R.3.10
3rd floor:
R.3.11
3rd floor:
R.3.12
3rd floor:
R.3.13
3rd floor:
R.3.14
3rd floor:
R.3.15
3rd floor:
R.3.16
3rd floor:
R.3.17
3rd floor:
R.3.19
Regular Class (Class A)
English Class (Class B)
No
Name
Group
1
dr. Gde Somayana, Sp.PD
B1
2
Dr. dr. Ni Putu Sriwidyani, Sp.PA
B2
3
4
5
6
7
8
Desak Kt. Ernawati, S.Si., Apt.,
M.Pharm., Ph.D
dr. Wayan Suryanto Dusak, Sp.OT
(K)
dr. Agus Roy Rusly Hariantana
Hamid, Sp.BP-RE
dr. I.G.N. Budiarsa, Sp.S
dr. Pontisomaya Parami, Sp.An.
MARS
dr. Ida. Ayu Putri Wirawati, Sp.PK
(K)
Departement
Internal
Medicine
Anatomy
Phatology
Phone
0816579888
081337115012
B3
Farmakologi
081236753646
B4
Orthopaedi
08123801878
B5
Surgery
08123511673
B6
Neurology
0811399673
B7
Anestesiology
08113800107
B8
9
Dr.dr. A.A Wiradewi Lestari, Sp.PK
B9
10
Dr.dr. I Gede Ngurah Harry Wijaya
Surya, Sp.OG
B10
Clinical
Phatology
Clinical
Phatology
Obsgyn
082145723828
08155237937
0811386935
Venue
(3rd floor)
3rd floor:
R.3.09
3rd floor:
R.3.10
3rd floor:
R.3.11
3rd floor:
R.3.12
3rd floor:
R.3.13
3rd floor:
R.3.14
3rd floor:
R.3.15
3rd floor:
R.3.16
3rd floor:
R.3.17
3rd floor:
R.3.19
CURRICULUM
AIM OF TRAVEL MEDICINE
1. To introduce the existence of Special Topics in the curriculum of the medical
profession.
2. To know general perspective of Travel Medicine
Udayana University Faculty of Medicine, DME
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Study Guide
Special Topics
3. To understand the science and it's practices of travelers medicine in the medical
profession.
4. To describe etiology, patophysiology, clinical features, diagnosis, and management of
travel related illness
5. To describe the 5 most common in travel related illness
LEARNING OUTCOMES
1. Know and can perform immunization and give chemoprophylaxis to prevent travelrelated illness
2. Understand the management of primary care practice specific for traveler
3. Diagnose, treat, and prevent traveler`s diarrhea
4. Diagnose, treat, refer, and prevent DVT
5. Diagnose, treat, refer, and prevent ACS
6. Manage traveler with respiratory disease who undergo air travel
7. Diagnose, treat, refer, and prevent traveler with heat exhaustion and heat stroke
8. Diagnose, treat, refer, and prevent traveler with near drowning
9. Diagnose, treat, refer, and prevent traveler with decompression syndrome after dive
CURRICULLUM CONTENT
1. Know and can perform immunization and give chemoprophylaxis to prevent travel-related
illness
a. Recognize the immunizations to prevent travel-related illness
b. Recognize the prophylaxis for malaria
2. Primary care practice for travel medicine
a. Understand the primary care practice specific for traveler
b. Recognize the management of primary care practice specific for traveler
3. Diagnose, treat, and prevent traveler`s diarrhea
a. Understand the definition of traveler`s diarrhea
b. Understand the etiology of traveler`s diarrhea
c. Describe the pathogenesis of traveler`s diarrhea
d. Recognize the clinical manifestation of traveler`s diarrhea
e. Recognize the management of traveler`s diarrhea
f. Understand the prevention of traveler`s diarrhea
4. Diagnose, treat, refer, and prevent DVT
a. Understand the predisposing factor of DVT
b. Describe the pathophysiology of DVT
c. Recognize the clinical presentation of DVT
d. Recognize the management of DVT
e. Understand the prevention of DVT
5. Diagnose, treat, refer, and prevent ACS
a. Understand the predisposing factor of ACS
b. Describe the pathophysiology of ACS
c. Recognize the clinical manifestation of ACS
d. Recognize the management of ACS
e. Understand the prevention of ACS
6. Manage traveler with respiratory disease who undergo air travel
a. Describe the flight environment
b. Recognize the physiological effects of exposure to altitude
c. Recognize the clinical pre-flight assessment
d. recognize fitness to flight condition
e. recognize respiratory disorders with potential complication for air travel
7. Diagnose, treat, refer, and prevent traveler heat exhaustion and heat stroke
a. Understand the definition of heat exhaustion and heat stroke
Udayana University Faculty of Medicine, DME
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Study Guide
Special Topics
b. Describe the pathophysiology of heat exhaustion and heat stroke
c. Recognize the clinical manifestation of heat exhaustion and heat stroke
d. Recognize the complication of heat exhaustion and heat stroke
e. recognize the management of heat exhaustion and heat stroke
8. Diagnose, treat, refer, and prevent traveler with near drowning
a. Understand the definition of near drowning
b. Describe the pathogenesis of near drowning
c. Recognize the clinical manifestation of near drowning
d. Recognize the complication of near drowning
e. recognize the management of near drowning
9. Diagnose, treat, refer, and prevent traveler with decompression syndrome after dive
a. Understand the definition decompression syndrome after dive
b. Describe the pathogenesis decompression syndrome after dive
c. Recognize the clinical manifestation decompression syndrome after dive
d. Recognize the complication decompression syndrome after dive
e. recognize the management decompression syndrome after dive
10. Animal bite Objectives
a. To describe why rabies continues to be a feared zoonotic disease.
b. To describe how is rabies spread
c. To describe disease that Rabies most commonly mimic
d. To understand how Rabies is diagnosed
e. To describe the current recommendation for Rabies treatment
f. To describe pre and post exposure prophylaxis
g. To describe clinical presentation of Rabies
h. To describe the clinical management of snake bite envenoming
i. To describe the clinical management of scorpion sting envenoming
LEARNING TIME-TABLE
CLASS ROOM : 3TH FLOOR, ROOM A 3.01
No
Days
Topics
B Class
1
Friday
Oct.13th
2017
Emerging Diseases
Related Worldwide
Travelling
Udayana University Faculty of Medicine, DME
Time
A Class
08.00-08.30
09.00-09.30
Learning
Activity
Lecture
Place
PIC
Class
room
Dr.Made Agus
Hendrayana,M.
ked
5
Study Guide
Special Topics
08.30-09.00
09.30-10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
Traveler`s diarrhea
2
3
4
5
Monday
Oct.16th
2017
Tuesday
Oct.17th
2017
Wednesday
Oct.18th
2017
Thursday
Oct.19th
2017
Air travel: Acute
Coronary Syndrome
Air travel:
thromboembolism
General perspective
of Travel Medicine.
- Pre travel assement
- Post travel illness
High altitude
Udayana University Faculty of Medicine, DME
12.00-12.30
12.30 - 14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
12.30 -14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
12.30 -14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
08.00-09.00
09.00-10.00
Lecture
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
Lecture
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
Lecture
Class
room
Library
Disc.
Room
Class
room
Class
room
Dr.Made Susila
Utama,Sp.PD
Facilitators
Team
dr. Luh Oliva
Saraswati
Suastika,Sp.JP
Library
Disc.
Room
Class
room
Class
room
Facilitators
Team
DR.Dr.Ketut
Suega Sp.PDKHOM
Library
Disc.
Room
Class
room
Class
room
Facilitators
Team
Prof.Dr.dr. Tuti
Parwati, SpPDKPTI
09.00-10.30
12.00-13.30
Individual
learning
(IL)
Library
10.30-12.00
13.30-15.00
Small Group
Discussion
(SGD)
Disc.
Room
Facilitators
12.00-12.30
11.30-12.00
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
Class
room
Team
08.00- 08.30
09.00-09.30
Lecture
Class
room
Dr. I Putu
Adiartha
Griadhi,M.Fis
6
Study Guide
Special Topics
Air travel: respiratory
disease related travel
6
7
8
Friday
Oct.20th
2017
Monday
Oct.23th
2017
Tuesday
Oct.24th
2017
08.30 - 09.00
09.30 - 10.00
Lecture
Class
room
09.00-10.30
12.00-13.30
Library
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
08.00- 08.30
09.00-09.30
Lecture
08.30 - 09.00
09.30 - 10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
Near drowning
08.00- 08.30
09.00-09.30
Diving
Decompression
Syndrome
08.30 - 09.00
Heat exhaustion and
heat stroke
Air travel: Fit to Flight
Immunization to
prevent travel-related
illness
Chemoprophylaxis for
travel related illness
Udayana University Faculty of Medicine, DME
Disc.
Room
Class
room
Class
room
Class
room
Dr.I Gst.Ngr.
Bagus Artana,
Sp.PD
Facilitators
Team
Dr.Made Susila
Utama,Sp.PD
Dr.I Md.Ady
Wirawan,MPH,
PhD
Library
Disc.
Room
Facilitators
Class
room
Team
Lecture
Class
room
09.30 - 10.00
Lecture
Class
room
DR.Dr. Tjok
Senapathi,Sp.
An
Dr. Anita
Devi,M.Si
09.00-10.30
12.00-13.30
Library
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
Student
Project
14.00-15.00
15.00-16.00
Plenary
Class
room
Team
08.00 - 08.30
09.00-09.30
Lecture
Class
room
08.30 – 09.00
09.30 – 10.00
Lecture
Class
room
Dr. I K Agus
Somia, SpPDKPTI
Dr. I K Agus
Somia, SpPDKPTI
09.00-10.30
12.00-13.30
Individual
learning
(IL)
Library
Disc.
Room
Facilitators
7
Study Guide
Special Topics
9
10
12
13
Wednesday
Oct.25th
2017
Thursday
Oct.26th
2017
Friday
Oct.27th
2017
Monday
Oct.30th
2017
10.30-12.00
13.30-15.00
12.00-12.30
12.30 -14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
08.00-09.00
09.00-10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
Animal Bite
08.00- 08.30
09.00- 09.30
Lecture
Marine Envenomation
08.30 - 09.00
09.30 - 10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Medical evacuation
Student
Project
Plenary
Disc.
Room
Facilitators
Class
room
Class
room
Team
DR.Dr. Tjok
Senapathi,Sp.
An
Library
Disc.
Room
Class
room
Class
room
Class
room
Facilitators
Team
Dr.A.A Yuli
Gayatri,Sp.PD
Dr.Dewi Dian
Sukmawati,
Sp.PD
Library
Disc.
Room
Class
room
Facilitators
Team
Preparation for final
test
Assessment
Team
MEETING OF STUDENT REPRESENTATIVES
In the middle of block period a meeting is designed among the student representatives of
every small group discussion, facilitators, and source person of the block. The meeting
discuss about the ongoing teaching and learning process, quality of facilitators, and lecturers
as the feedback to improve the next process.
This meeting is held on Saturday when the students are free from lecture.
Udayana University Faculty of Medicine, DME
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Study Guide
Special Topics
MEETING OF THE FACILITATORS
All facilitators are invited to discuss all block activities with block contributors 1 week after
meeting onf students representatives
ASSESMENT METHOD
Assessment will be held on end of the block period. The time provision is 100 minutes. The
number of MCQ is 100 with passing point ≥ 70
STUDENT PROJECT GROUPS AND TOPICS
BLOCK SPECIAL TOPIC TRAVEL MEDICINE SEMESTER 7
Udayana University Faculty of Medicine, DME
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Study Guide
Special Topics
SGD
GROUP
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
SGD
GROUP
B1
B2
B3
B4
B5
B6
B7
B8
B9
B10
B11
B12
TOPIC
Supervisor Student
Project
Bug Bites
Jet Lag
Mental Health and Travel
Road Safety
Sex Tourism
Traveling with a Disability
Humanitarian Aid Workers
Last-Minute Travelers
Long-Term Travelers and Expatriates
Pregnant treveler
Elderly traveler
Travelling with children
TOPIC
Supervisor Student
Project
Travelers with Weakened Immune Systems
Travelers with Chronic Illnesses
Adventure Travel
Cruise Ship Travel
Medical Tourism
Travel to Cold Climates
Travel to Mass Gatherings
Fit to dive
Travel Health Insurance
Travel to altitude after diving
Hajj travel
Wilderness medicine
LEARNING PROGRAM
LECTURE 1
Emerging Diseases Related Worldwide Travelling
It is believed that increased global travel is the reason for the recent resurgence of many
infectious diseases in the world. International movement of individuals, populations, and
products is one of the major factors associated with the emergence and reemergence of
infectious diseases as the pace of global travel and commerce increases rapidly.
The number of people traveling internationally is increasing every year, and more people
are taking trips to remote parts of the world, which often have unfamiliar health problems
Udayana University Faculty of Medicine, DME
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Study Guide
Special Topics
as well as underdeveloped health care services. Many travelers are also unaware of
potential hazards in different parts of the world and do not take the necessary
precautions, such as getting necessary vaccines or taking preventive medicine.
Travel can be associated with disease emergence because (1) the disease arises in an
area of heavy tourism, (2) tourists may be at heightened risk because of their activities, or
(3) because they can act as vectors to transport the agent to new areas.
Many of the newly discovered infections have actually been in existence for a long time,
but doctors have not seen them in areas where new outbreaks occur. With people's ability
today to travel anywhere in the world within 36 hours or less, formerly little-known
infections are picked up and rapidly spread to areas where they previously did not exist.
LECTURE 2
Traveler’s diarrhea
Traveler’s diarrhea (TD) is the most common travel-related health problem that affects up
to half of travelers during their first 2 weeks abroad. A case of TD is described as the
sudden onset of loose, watery stools associated with abdominal pain, fever or tenesmus.
Fever occurs commonly and blood is noted in stools rarely. Nausea and vomiting are
also common in the first few hours, adding to the discomfort and water loss. TD usually
presents as an acute illness, resolving completely in less than a week. Bacteria are the
most common cause of TD and ETEC (enterotoxigenic E. coli) is the most common
bacterial cause. Salmonella, Shigella and campylobacter make up the majority of
remaining bacterial pathogens. Host factors such as age, pre-existing immunity,
underlying medical conditions and genetic factors play a role in susceptibility to TD.
Effective pre-travel counseling may motivate some travelers to avoid risky food and
drink, which may in turn reduce diarrheal incidence. Since most TD is bacterial in origin,
traveling with appropriate antibiotics for treatment and prevention is also important.
LECTURE 3
Air travel and ACS
Cardiovascular events are the main cause of deaths among travelers and of in-flight
emergencies on commercial aircraft. Persons with underlying heart disease should review
their itineraries with a physician prior to departure; travel in harsh environments or to
remote destinations is not wise.
LECTURE 4
Air travel and thromoembolism
DVT and thromboembolism have long been proposed as possible complication of air
travel. Pulmonary embolism (PE) has been suggested as a culprit in deaths related to air
travel, although evidence linking air travel to DVT has been somewhat elusive. Many
studies found that 18% of sudden deaths among long distance travelers were attributable
to PE.
LECTURE 5
Udayana University Faculty of Medicine, DME
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Study Guide
Special Topics
General perspective of Travel Medicine
Travel Medicine is the branch of medicine that deals with the prevention and management of
health problems of international travelers. It is concerned with both prevention and
management of illness related to travel
Why TM ?
• Increased trend of travelers : many more people are travel abroad
•
Scope has largely evolved in response to changing of travel trend, such as :
•
The reason for travel and types of travel has become much more diverse.
•
Organized package tour remain popular, but many traveler are becoming more
adventurous and choose to backpack out with ‘tourist‘ areas, go on expedition
into remote areas sometime in several countries and work as volunteers for
prolonged period.
•
Travel for business take a common place.
•
In addition, potentially vulnerable groups of people such as the very young, the
elderly, pregnant women and those with underlying medical problems or
disabilities and immune compromized are traveling more than ever before.
As a result of these changes, more people need information, more advise and more
prophylactic prior and during travel
Important component of TM includes not only vaccination and prophylaxis for malaria,
but also advise on accident prevention, sexual health and guidance on contraception,
safety food and water, hygiene and other precautions
History of TM ?
The disciplines of TM evolved initially from infectious disease, tropical and preventive
medicine and historically from quarantine and international health regulations, the
subject encompasses the whole range of clinical and preventive medicine; this
includes care of the travelers with special needs such as, children, the elderly,
pregnant women, and person with underlying medical problems: cardiovascular,
respiratory, kidney, GIT, metabolic , neurological, malignant, HIV and behavioral dis.
TM concerned with both prevention and management of illness related to travel
Illness may result from exposure to infection, accidents, psychological upset,
environmental hazards and political unrest
The specialty of TM therefore is truly interdisciplinary and international specialty
involving numerous disciplines including , tropical medicine, infectious diseases,
microbiology, public health and nursing.
Continued surveillance of illness and disease both in the host countries and returning
travelers is necessary to allow sound risk assessment to be made for intending
travelers. This is a crucial area for development within the specialty
Dissemination of information regarding real or potential risks can both prevent illness
and increase detection of illness in travelers who have returned to their country of
origin. This may have important public health implications when considering
secondary cases or outbreaks as a results of travelers returning with infections
Risks in Travel
Risk in travel can be non communicable and communicable disease
Non-Communicable disease :
• Aircraft travel, reduced O2, pressure and humidity
• Motion sickness
• Jet Lag
Udayana University Faculty of Medicine, DME
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Study Guide
Special Topics
•
•
•
•
•
•
•
•
•
•
DVT’s and immobility
Altitude
Heat/cold/humidity
Sunburn
Water safety
Accidents and Injuries
Animals and Insects
Accidents, vehicles, marine
Snakes, (vipers, cobras and kraits )
Marine stings
There are many potential diseases spread via :
• Food and water
• Insect vectors
• Soil and water
• Sexual contact, Body-fluid exposures
• Animals
LECTURE 6
High altitude illness
High altitude medicine is one of medical science that discuss human adaptation that occur
in high altitude environment. It is importance for us to study this topic because some
people travelling to high area, expedition to the mountain, and excellent physiology
research in high altitude. Understanding human adaptation to high altitude provide us
importance information needed for planning the trip and avoid many disease that may
occur.
Aclimatization is the key point during high altitude travelling. Failure in this process will
affect our body condition manifest as several high altitude problems. Acute Mountain
Sickness (AMS) is the most common syndrome occur in high altitude, followed by high
altitude cerebral edema, and hipoxic hipoksia. As a medical doctor it is importance to
understand this topic, especially in region that choosen as traveller destination.
LECTURE 7
Air travel and respiratory disease related travel
For the vast majority commercial flights are safe, but a rising number are at risk of
respiratory complications triggered by hypoxemia, immobility and dehydration. Patients
with severe airways disease require assessment before flying. It is anticipated that these
patients will have already seen a respiratory specialist for their condition.
LECTURE 8
Heat exhaustion and heat stroke
Heatstroke (HS) is the most serious of the syndrome associated with excess body heat. It
is defined as condition in which body temperature is elevated to such level that body
tissue damage occurs, giving rise to a characteristic multiorgan clinical and pathological
syndrome. The severity depends on the degree of hyperthermia and its duration.
Heatstroke is a medical emergency that can be fatal if not diagnosed and treated
promptly. The literature differentiates between two entities of heatstroke: exertional
heatstroke (EHS) and classic heatstroke. The presentation of EHS is usually acute, the
prodorme, occurring in 25% of casualties, consists dizziness, weakness, nausea,
confusion, disorientation, drowsiness and irrational behavior, this may last from minutes to
Udayana University Faculty of Medicine, DME
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hour. ES should be the working hypothesis in any cases of collapse during exercise or
immediately, apparently healthy individual whose body core temperature is high and who
presents with neurological sign (from aggressiveness to coma). Prolonged exertion, warm
climate, very high body core temperature and dry skin are typically linked with EHS.
Treatment of HS is supportive. Cooling should be initiated vigorously immediately upon
collapse. The most practical and efficient method of cooling is the use of large quantities
of tap water, which is readily available. No drug is effective in reducing body temperature.
LECTURE 9
Air travel and Fit to Fly
Each year, approximately 3.3 billion people are estimated to travel by aircraft.
Furthermore, the passenger numbers are expected to reach 7.3 billion by 2034, as
predicted by the International Air Transport Association (IATA). While many of these
people have medical conditions that pose no risk to themselves or to other passengers,
there are some medical conditions that should preclude flying or require pre-flight
evaluation.
Most airlines have medical passenger policies to determine fitness to fly, in order to
minimize the risk of disruption to other passengers and crew, the likelihood of the aircraft
diversion, and risks to the passenger’s safety. A passenger medical information form is
commonly used, which asks details from both patient and doctor, about diagnosis,
prognosis, desired supplemental oxygen, food, etc.
Reduced oxygen tension, pressure changes and reduced space and mobility are the
principal effects on the health of the air-traveler. Modern commercial airliners fly with a
cabin altitude of between 4000 and 8000 feet (1200 and 2400 m) when at cruising altitude
(30.000-39.000 feet), which means a reduction in ambient pressure of the order of 20%
compared with sea level and a consequent reduction in blood oxygen saturation of about
10%. The cabin air is relatively dry, and the limited room available in the non-premium
cabin may be a factor to be considered.
In determining the passenger’s fitness to fly, a basic knowledge of aviation physiology and
physics can be applied to the pathology. Any trapped gas will expand in volume by up to
30% during flight, and consideration must be given to the effects of the relative hypoxia
encountered at a cabin altitude of 8000 feet (2400 m) above mean sea level.
LECTURE 10
Near drowning
Traditionally, the terminology used to describe submersion injuries has been confusing
and impractical. In the past, drowning referred to death within 24 hours of suffocation from
submersion in a liquid, whereas near-drowning described victims who survived at least 24
hours past the initial event regardless of the outcome. In 2005, the World Health
Organization (WHO) published a new policy defining drowning in an attempt to clarify
documentation and better track submersion injuries worldwide.
Drowning was defined as “the process of experiencing respiratory impairment from
submersion/immersion in liquid.” Furthermore, the WHO policy states that “drowning
outcomes should be classified as: death, morbidity, and no morbidity. … Use of the terms
wet, dry, active, passive, silent, and secondary drowning should no longer be used.” As
such, the term near-drowning should not be used, and the association of the term
drowning with a fatal outcome should be abandoned.
Risk Factors
Ethanol consumption in proximity with water is a major risk factor for submersion injury or
death. Acute ethanol intoxication may be a contributing factor in 30 to 50% of drownings
among adults and adolescents.
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In one study of boating fatalities, most of which were due to drowning, an association
between blood ethanol concentration and risk of death from drowning while using
watercraft was established Odds ratios of fatality from drowning followed a trend from 2.8
(95% confidence interval [CI] 1.6, 4.8) for a blood ethanol concentration (BEC) of 1 to 49
mg/dL to 37.4 (95% CI 16.8, 83.0) for a BEC of 150 mg/dL or greater compared with
sober case controls.
Pathophysiology
Unexpected submersion triggers breath-holding, panic, and a struggle to surface. Air
hunger and hypoxia develop, and the victim begins to swallow water. As breath-holding is
overcome, involuntary gasps result in aspiration The quantity of fluid aspirated, rather
than the composition, determines subsequent pulmonary derangement.
Sign & Symptom
Many submersion injuries are witnessed. Toddler drownings are an important exception,
however, often occurring because of a lapse in supervision. Occasionally, the history of
coughing, choking, or vomiting in a patient found near a body of water suggests the
diagnosis. Signs of pulmonary injury may be obvious in a submersion victim who is
hypoxic, cyanotic, and in obvious respiratory distress or arrest.
More subtle clues, such as increased respiratory rate and audible rhonchi, rales, or
wheezes, should alert the clinician to evolving respiratory compromise. Submersion
victims swallow a significantly greater volume of water than is aspirated, and gastric
distention from positive-pressure ventilation during rescue is common. As a result, 60% of
patients vomit after a submersion event. Aspiration of gastric contents greatly compounds
the degree of pulmonary injury and increases the likelihood that acute respiratory distress
syndrome will ensue. In addition, aspiration of particulate contaminants such as mud,
sewage, and bacteria may obstruct the smaller bronchi and bronchioles and greatly
increase the risk of infection both bacterial and fungal in nature.
Prognostic
Many factors may help predict patients who will survive a submersion injury neurologically
intact. Submersion victims who arrive in the emergency department alert with normal
hemodynamics are unlikely to experience neurologic impairment. Circumstantial variables
that portend a poor outcome include victim age younger than 3 years, submersion for
longer than 5 minutes, and initiation of cardiopulmonary resuscitation (CPR) more than 10
minutes after rescue. With the exception of victim age, however, such measurements are
generally either unknown or inaccurately estimated at the time of a patient's arrival in the
emergency department. Objective findings on emergency department arrival that are
associated with an unfavorable prognosis include hypothermia, severe acidosis,
unreactive pupils, a Glasgow Coma Scale score of 3, and asystole or the need for
ongoing CPR.
Neurologically intact survival is reported for individual patients even with several of these
factors present, and none of several proposed scoring systems using combinations of
these variables shows 100% predictive power
LECTURE 11
Diving decompression syndrome
Decompression syndrome is the most common consequence of diving activities.
Knowledge about this condition very important because of its different approach and
management.
LECTURE 12
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Immunization to prevent travel-related illness
Pre-travel immunization divide into three categories : recommended as part of routine
health maintenance irrespective of international travel; may be required into a country;
and recommended because of risk during travel.
LECTURE 13
Chemoprophylaxis for travel related illness (Malaria)
Malaria is one of the most severe infectious diseases of travelers. Nearly all cases in
travelers are preventable. Prevention and best management of malaria include
awareness of risk, avoidance of mosquito bites, compliance with chemoprophylaxis, and
prompt diagnosis in the event of a febrile illness either during or on return from travel.
LECTURE 14
Medical Evacuation
Transport pasien dalam keadaan kritis mempunyai resiko pada pasien sehingga
merupakan tantangan yang sangat besar bagi para klinisi. Alasan untukmelakukan
transport pada pasien adalah untuk mendapatkan pelayanankesehatan tambahan,
diagnostik atau terapiutik yang lebih canggih tidaktersedia.
Pasien dalam keadaan kritis memiliki sedikit atau tidak samasekali cadangan fisiologis
tubuhnya. Memindahkan pasien seperti tersebut menimbulkan suatu masalah tersendiri
dan dapat menimbulkan suatu perubahan fisiologis yang merugikan dan dapat
mengancam keselamatan pasien saat transportasi. Sehingga transport pasien kritis harus
dilakukan dengan persiapan yang matang dan perhatian yang seksama dan detail pada
hal-hal yang harus diperhatikan.
Guideline atau pedoman sudah tersedia dan prinsip-prinsip utama dalam melakukan
transport pasien kritis meliputi 5P:
1. Planning (perencanaan)
2. Personnel (jumlah yang cukup disertai dengan kemampuan yang sudah terstandarisir
dalam evakuasi pasien kritis).
3. Properties (alat yang dipakai dalam transportasi)
4. Procedures (alat yang dipakai mengukur kestabilan keadaan pasien sebelum dan saat
diberangkatkan)
5. Passage (pilihan rute dan tehnik transport).
LECTURE 15
Animal Bite
Rabies, Herpes B and envenoming are the diseases that result from bites by rabid
mammals or bites and stings by venomous animals, especially snakes and scorpions. In
all cases, appropriate early treatment, including therapeutic anti-sera, can prevent lifethreatening systemic spread of the virus or venom toxins.
Introduction
In recent years, the growth of the adventure travel market in particular eco-tourism,
extreme dive and wilderness safari has increased opportunities for travelers to encounter
dangerous species. For travelers to remote destinations pre-travel safety education
should be extended to include first aid for bite and sting injuries and potentially,
provisioning of standby antibiotics for prophylaxis of high-risk wounds
Mammals Bite or Scratch Wounds
Animal bites present a risk for rabies, herpes B, tetanus and other bacterial infections.
Animals’ saliva can be so heavily contaminated. Rabies is present on all continents with
the exception of Antartica, but more than 95% of human deaths occur in Asia and Africa.
Rabies occurs in more than 150 countries and territories. Worldwide, more than 55 000
people die of rabies every year, and 40 % of people who are bitten by suspect rabid
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animals are children under 15 years of age.. In travelers, bite wounds are mostly causes
by dogs (51%), monkeys (21%) and cats (8%). The wounds inflicted are often a
combination of punctures, avulsions, abrasions and crush injuries, the last of which may
not be apperent until compartment syndrome develops. Rabies virus, a rhabdovirus
present in infected animal’s saliva is inoculated into the bite wound, enter peripheral
nerves and spreads to the central nervous system where it causes a lethal
encephalomyelitis. Fortunately the availability of efficacious and save vaccines and
immunoglobulin has prevented many fatalities and almost 10 million people receive post
exposure treatment annually after potential rabies exposure, mostly following dogs bites.
In Addition, increase public and clinician awareness about the risk associated with an
injury from a macaque, improved first aid after exposure, the availability of better
diagnostic test, and improved antiviral therapeutics have decreased the case-fatality ratio
to 20% in treated people.
Before departure, travelers should have a current tetanus vaccination or documentation of
having received a booster vaccination within the previous 5-10 years. Travel health
provider should assess a traveler’s need for pre-exposure rabies immunization. In order
to prevent infection, all wounds should be promptly cleaned with soap and water, and the
wound promptly debrided, if necrotic tissue, dirt or other foreigner materials is present.
Travelers who might have been expose to rabies or Herpes B should contact a reliable
health care provider for advice about rabies or Herpes B post-exposure prophylaxis.
Snake bites
Snakebite accounts for the majority of severe envenoming in tropical developing
countries. Physicians with experience treating snakebite generally agree that while
elapids (cobra and kraits) account for the greatest number of deaths, vipers account for
the greates number of bites. Viper venoms is rich in enzymes, which cause local pain,
swelling, tissue damages, coagulopathy and for some species, damage to the kidneys,
adrenals and pituitary gland. Venom from cobras may be myonecrotic, leading to
devastating tissue injury; neurotoxic, leading to respiratory failure or possess mixed
activity. Poisonuos snakes are hazards in many locations, although deaths from
snakebites are rare. If snakebite result in intravenous injection of venom, syncope and
death may occur quickly. Deaths occurring within hours usually result from paralysis of
respiratory muscles following bites from kraits, mambas, coral snakes and Philippine
cobra. Death after 12 hours is likely to be caused by defibrination-related hemorrhage and
shock following viper bite. In developing regions, patients may suc-cumb days after the
bite, due to complications such as renal failure, secondary wound infection or failure of
mechanical ventilation due to power outages.
A large percentage of cobra and viper bites, between 25%-40% do not result in
envenoming and may be treated conservatively, while continuing to observe for delayed
onset of symptoms.
For extra precaution, when practical, travelers should wear heavy, ankle-high or higher
boots and long pants when walking outdoors in areas possibly inhabited by venomous
snakes. Travelers should be advised to seek immediate medical attention any time a bite
wound breaks the skin or when snake venom is injected into their eyes or mucous
membranes. Immobilization of the infected limb and application of a pressure bandage
that does not restrict blood flow are recommended first aid measures while the victim is
moved as quickly as possible to a medical facility. Specific anti-venoms are available for
some snakes in some areas, so trying to ascertain the species of snakes that bite the
victim may be critical.
Insect Bites and Scorpion Stings
Venom from insects can produce severe allergic reactions and lead to life-threatening
anaphylactic shock. More commonly, insect bites and stings are painful and produce local
reaction (redness and swelling) at the site.
The most medically significant venomous arthropods belong to order Hymenopthera
which include; bees, wasps and stinging ansts . Together the members of Hymenopthera
account for the greatest number of stings injuries and are responsible for considerable
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-
morbidity and in some case death secondary to hypersensitivity reaction. Most
Hymenopthera venom contains serotonin, histamine and in some tropical hornet species,
acetylcholine. The sting injuries cause immediate pain, which tends to decrease over min
30 in the case of honeybees (Apidae) or hours in the case of large hornets (Vespidae).
Honeybees have a barbed stinger. When the bee attempts to fly away, it is eviscerated,
leaving the stinger and the contracting venom gland behind. When present, the stinger
gland complex should be immediately removed with minimal regard to method, as even
minor delays will increase the amount of venom that is delifvered. Additional care;
washing with soap and water, verifying tetanus immunization and monitoring for infection.
Oral non-steroidal antiinflammatory agent (NSAIDs) such as ibuprofen are effective in
reducing pain, and swelling, but are little value after swelling is established. Oral
antihistamines are effective at reducing local pruritus which appears minutes to hours
after the sting injuriy. Cold pack relieve pain associated with Hymenopthera sting injuries.
Treatment of hypersensitivity reactions should be initated as soon as systemic symptoms
appear. The most effective therapy is prompt treatment with 1:1000 epinephrine
hydrochloride (0.25-0.5 ml, subcutaneous). Patients with severe reactions are likely to
need a second injection. Sting injuries that develop pain, erythema and lymphadenopathy
should be treated with antibiotics with activity against Gram positive skin flora.
Some spider species, such as the hobo spider (Tageneria) and violin spider group (violin
or recluse spider; Loxosceles) and several tipes of wolf spider (Lycosa) possess venom
capable of causing necrotic skin lesions. In the case of Loxosceles spider, necrosis may
be severe. Systemic effect of Loxosceles spiders include renal failure, hepatic
insufficiency and hemolysis. No FDA approved polyspecific antivenin is available for the
treatment of Loxosceles envenoming and treatment remains unsatisfying and supportive.
Widow spiders (Latrodectus) have a worldwide distribution and are responsible for a
significant number of neurotoxic envenoming. All widow spiders are a web-dwelling
species and it is a female spiders that are responsible for human bites. Widow spiders
prefer to build webs near attractant for insects such as trash dump, refuse pile and
latrines. Bites by widow spiders may initially be mild, however rapid onset of cramping
and muscular spasms cause considerable pain. Small children are at increased risk of
envenoming and a bad outcome. Highly effective antivenins against widow spider bites
are produced in Australia, South Africa and USA.
Scorpion are responsible for a significant number of fatalities in Central America, India,
and North Africa. Most fatalities involve small children and debilitated patients. Scorpion
venoms which are especially lethal in young children, release autonomic nervous system
mediators causing myocardial damage, cardiac arrhythmias, pulmonary edema, shock,
paralysis, muscle spasm and pancreatitis. Early administration of anti-venom is highly
effective, together with intensive care support in severe cases. In addition, infectious
diseases can be spread by insect bites, especially in tropical countries. Travelers are
likely to be envenomed when they take a shower and step on scorpions that have fallen in
to the tub. Many scorpions seek shelter in footwear or between folded clothing, leading to
unfortunate encounters. Antivenin is produced against several of the more toxic species
such as the Middle Eastern Leiurius and American Centruroides. In addition to antivenin ,
neorotoxic bites and stings may be treated with a compression bandage as for neurotoxic
snake venoming.
Wearing protective clothing, applying insect repellents containing DEET are important
preventive measures.
The general treatment include;
Ice or cold pack and sting relief swabs (applied topically) will help alleviate local pain and
swelling.
Any bite or sting can become infected and should therefore be examined at regular
intervals for progressive redness, swelling pain or pus drainage
Oral anti-histamines, such as diphenhydramine 25 to 50 mg every hours are helpful in
relieving the itching, rash and swelling associated with many insect bites and stings
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1.
2.
3.
4.
5.
6.
If anaphylactic shock occurs it must be treated immediately with epinephrine and
antihistamines.
A specifics antidote is available for those suffering severe symptoms
Reference
World Health Organisation. Rabies. Geneva: WHO, 2011. URL: http//www.who.int/ith
Susan E., Charles E., Daniel Fishbein, Cathleen A. Hanlon, Boonlert Lumlertdacha,
Marta Guerra, et al. Human Rabies Prevention --- United States, 2008. MMWR
Recommendations of the Advisory Committee on Immunization Practices. May 7, 2008 /
57(Early Release);1-26,28
World Health Organization. Rabies. Current strategies for human rabies pre and postexposure prophylaxis, September 2010
Meslin FX, Hemachuda T, Wilde H, Gongal G. WHO Standards for Rabies Control. At The
Occasion of the OIE Global Conference on Rabies Control: towards sustainable
prevention at the source, Incheon Republic of Korea 7-9 September 2011
WHO Guide for Rabies Pre and Post –exposure prophylaxis in Humans. Department of
Neglected Tropical Disease-Neglected Zoonotic Disease Team. Revised 15 Juni 2010
Weiss EA. A Comprehensive Guide to Wilderness and Travel Medicine. 3 rd ed. Adventure
Medical Kits, 2005: 121-133
LECTURE 16
Marine injuries and envenomations
Poisoning, envenomation, and direct trauma are all possible in the marine environment.
Ciguatera poisoning can result from ingestion of predatory fish that have accumulated
biotoxins. Symptoms can be gastrointestinal or neurologic, or mixed. Management is
mostly symptomatic. Scombroid poisoning results from ingestion of fish in which
histamine-like substances have developed because of improper refrigeration.
Gastrointestinal and systemic symptoms occur. Treatment is based on antihistamines.
Envenomations from jellyfish are painful but rarely deadly. Household vinegar deactivates
the nematocysts, and manual removal of tentacles is important. Treatment is
symptomatic. Heat immersion may help with the pain. Stingrays cause localized damage
and a typically severe envenomation. The venom is deactivated by heat. The stingray
spine, including the venom gland, typically is difficult to remove from the victim, and
radiographs may be necessary to localize the spine or fragment. Surgical débridement
occasionally is needed. Direct trauma can result from contact with marine creatures.
Hemorrhage and tissue damage occasionally are severe. Infections with organisms
unique to the marine environment are possible; antibiotic choices are based on location
and type of injury. Shark attacks, although rare, require immediate attention.
LEARNING TASK
LEARNING TASK 1
Emerging & Re-emerging Diseases
Related Worldwide Travelling
Case :
A family from Indonesia has plan a vacation to Hong Kong and China mainland next
week. They came to you to get some advices.
Learning Task:
1. Explain any diseases in Hong Kong and China mainland that needs to be alerted by
this family!
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2. Describe the each way transmission of that diseases!
3. Explain to that family the preventive measures so they can prevent the diseases!
4. How the SARS and AVIAN FLU Disease can spread worldwide?
5. Describe the transmission mode of Legionnaire’s disease!
6. Describe the relationship between the Tourism and Legionnaire’s disease!
7. Explain the mechanism of MERS-Cov spread from animals to infect humans through!
8. Explain how to prevent MERS-Cov infection!
9. Describe the clinical signs and symptoms of Ebola virus infection!
10. Explain the Ebola virus transmission!
Self-assessment:
1. What is the agent of Legionnaire’s disease?
2. What is their habitat?
3. Describe the clinical signs and symptoms of Legionnaire's disease!
4. Describe the clinical signs and symptoms of MERS-Cov infection!
5. What is the characteristic of Ebola virus?
LEARNING TASK 2
Traveler’s diarrhea
Learning Task :
Traveler group from Netherland come to emergency dept of private hospital with diarrhea
for 2 days, diarrhea more than 10 times for half day, stools without blood and slym, water
only. Nausea, vomiting and abdominal pain was found. They have history fast food dinner
in restaurant.
1. What is the possibility a cause of diarrhea in this ase?
2. How the management and treatment must you done in this case?
3. What is your suggest to travelers for prevention traveler diarrhea ?
Self Assessment
1. Describe etiology of Traveler’s Diarrhea
2. Describe pathogenesis of Traveler’s Diarrhea
3. Describe clinical pattern of Traveler’s Diarrhea
4. Plan for management of of Traveler’s Diarrhea
5. Describe complication
6. t may happen
7. Describe prevention of Traveler’s Diarrhea
LEARNING TASK 3
Air
Air travel
travel and
and Acute
Acute Coronary
Coronary
Syndrome
Syndrome (ACS)
(ACS)
Case :
A 55 years old man, British, fat, smoker, complain pain on his left chest, become worst and
feel difficult to breath. He just arrived in Denpasar after has 4 hours flight from Thailand.
Learning Task :
1. What other anamnesis should be added to this case?
2. What kind of physical examination should be focused for this patient ?
3. What kind of other supported examinations suggested for the patient ?
4. What is the possible diagnose for this case ?
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5. What kind of early emergency treatment you should do for the patient ?
Self assessment
1. Describe the predisposition factors for ACS related to the air travel !
2. Describe the trigers for ACS related to the air travel !
3. Describe the mechanism of ACS related to the air travel !
4. Describe how to prevent ACS during flight trip !
LEARNING TASK 4
Air travel and thromboembolism
Case :
A 55 years old man, American, fat, smoker, complain his left lower limb is swelling, painful,
cramp and pain on pressure. He just arrived in Denpasar after has 10 hours flight from United
States.
Learning Task:
1. What other anamnesis should be added to this case?
2. What kind of physical examination should be focused for this patient ?
3. What kind of other supported examinations suggested for the patient ?
4. What is the possible diagnose for this case ?
Self assessment :
1. Describe the predisposition factors for venous thromboembolism related to the air
travel
2. Describe the mechanism of venous thromboembolism related to the air travel
3. Describe how to prevent venous thromboembolism during long flight trip
LEARNING TASK 5
General
General perspective
perspective
of
of Travel
Travel Medicine
Medicine
Case:
A 28 year old woman from Swiss, come to you and ask your advise due to her plan to go to
Lovina to join a Yoga training program for 4 weeks
Learning Task :
1.
What ki
Special Topics
Udayana University Faculty of Medicine, DME
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TIME TABLE
TIME
Activity
PIC
Oct.13th – Oct 26th,2017 Learning Activity
Oct 27th ,2016
Preparation for final test
th
Oct 30 ,2016
Evaluation
Coordinator
Teams
MEMBERS TEAM
No
Name
1
dr. Made Agus Hendrayana, M.Ked (Coordinator)
2
3
5
6
7
Prof.DR.Dr. Tuti Parwati Merati, SpPD-KPTI
dr. I Ketut Agus Somia, SpPD-KPTI
dr. Anita Devi,M.Si
Dr.dr. Tjok Senapathi,Sp.An KAR
dr. I Made Ady wirawan,MPH,PhD
Department
Phone
Microbiology
08123921590
Internal medicine
Internal medicine
Hyperbaric
Anestesiologi
Public Health
08123806626
08123989353
081805505911
081337711220
081239394465
Department
Internal Medicine
Internal Medicine
Internal Medicine
Microbiology
Cardiology
Hyperbaric
Internal Medicine
Anestesiologi
Internal Medicine
Internal Medicine
Internal Medicine
Public Health
Fisiology
Phone
08123806626
08123989353
08123994203
08123921590
081330530247
081805505911
08123815025
081337711220
081338728421
08123803985
08123320380
081239394465
081999636899
LECTURERS
No
1
2
3
4
5
6
7
8
9
10
11
12
13
Name
Prof. DR. dr. Tuti Parwati Merati, SpPD-KPTI
dr. I Ketut Agus Somia, SpPD-KPTI
dr.i Gusti Ngurah Bagus Artana,Sp.PD
dr.Made Agus Hendrayana,M.Ked
dr. Luh Oliva Saraswati Suastika,Sp.JP
dr. Anita Devi,M.Si
dr. Made Susila Utama,Sp.PD-KPTI
Dr.dr. Tjok Senapathi,Sp.An KAR
DR.dr.Ketut Suega,Sp.PD-KHOM
dr.A.A.Yuli Gayatri,Sp.PD
dr. Ni Made Dewi Dian Sukmawati,Sp.PD
dr. I Made Ady wirawan,MPH,PhD
dr.I Putu Adiartha Griadhi,M.Fis
~ FACILITATORS ~
No
1
Name
dr. Ketut Sudiasa, Sp.B(K) Trauma
Udayana University Faculty of Medicine, DME
Group
Departement
A1
Surgery
Phone
08123811106
Venue
(3rd floor)
3rd floor:
R.3.09
2
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Special Topics
2
3
4
5
6
7
8
9
10
Dr. dr. Tjok G.A Senapathi, Sp.An.
KAR
dr. Ni Made Dewi Dian Sukmawati,
Sp.PD
dr. Firman ParulianSitanggang,
Sp.Rad(K)RI
dr. I GstNgr. Wien Aryana, SpOT (K)
Dr.dr. IGAA Praharsini, SpKK,
FINSDV
Dr. Luh Made Indah Sri
HandariAdiputra, S.Psi., M.Erg
Dr.dr. AA. Mas Putrawati T., Sp.M(K)
dr. I Gede Budhi Setiawan,
Sp.B(K)Onk
dr. I Kadek Susila Surya Darma,
M.Biomed, Sp.JP, FIHA
081337711220
A2
Anestesiology
A3
Internal
Medicine
08123320380
A4
Radiology
081337165566
A5
Orthopaedi
0811385263
A6
Dermato
venerology
08123888794
A7
Fisiologi
081337095870
A8
Opthalmology
08123846995
A9
Surgery
08123923956
A10
Cardiology
08113853151
3rd floor:
R.3.10
3rd floor:
R.3.11
3rd floor:
R.3.12
3rd floor:
R.3.13
3rd floor:
R.3.14
3rd floor:
R.3.15
3rd floor:
R.3.16
3rd floor:
R.3.17
3rd floor:
R.3.19
Regular Class (Class A)
English Class (Class B)
No
Name
Group
1
dr. Gde Somayana, Sp.PD
B1
2
Dr. dr. Ni Putu Sriwidyani, Sp.PA
B2
3
4
5
6
7
8
Desak Kt. Ernawati, S.Si., Apt.,
M.Pharm., Ph.D
dr. Wayan Suryanto Dusak, Sp.OT
(K)
dr. Agus Roy Rusly Hariantana
Hamid, Sp.BP-RE
dr. I.G.N. Budiarsa, Sp.S
dr. Pontisomaya Parami, Sp.An.
MARS
dr. Ida. Ayu Putri Wirawati, Sp.PK
(K)
Departement
Internal
Medicine
Anatomy
Phatology
Phone
0816579888
081337115012
B3
Farmakologi
081236753646
B4
Orthopaedi
08123801878
B5
Surgery
08123511673
B6
Neurology
0811399673
B7
Anestesiology
08113800107
B8
9
Dr.dr. A.A Wiradewi Lestari, Sp.PK
B9
10
Dr.dr. I Gede Ngurah Harry Wijaya
Surya, Sp.OG
B10
Clinical
Phatology
Clinical
Phatology
Obsgyn
082145723828
08155237937
0811386935
Venue
(3rd floor)
3rd floor:
R.3.09
3rd floor:
R.3.10
3rd floor:
R.3.11
3rd floor:
R.3.12
3rd floor:
R.3.13
3rd floor:
R.3.14
3rd floor:
R.3.15
3rd floor:
R.3.16
3rd floor:
R.3.17
3rd floor:
R.3.19
CURRICULUM
AIM OF TRAVEL MEDICINE
1. To introduce the existence of Special Topics in the curriculum of the medical
profession.
2. To know general perspective of Travel Medicine
Udayana University Faculty of Medicine, DME
3
Study Guide
Special Topics
3. To understand the science and it's practices of travelers medicine in the medical
profession.
4. To describe etiology, patophysiology, clinical features, diagnosis, and management of
travel related illness
5. To describe the 5 most common in travel related illness
LEARNING OUTCOMES
1. Know and can perform immunization and give chemoprophylaxis to prevent travelrelated illness
2. Understand the management of primary care practice specific for traveler
3. Diagnose, treat, and prevent traveler`s diarrhea
4. Diagnose, treat, refer, and prevent DVT
5. Diagnose, treat, refer, and prevent ACS
6. Manage traveler with respiratory disease who undergo air travel
7. Diagnose, treat, refer, and prevent traveler with heat exhaustion and heat stroke
8. Diagnose, treat, refer, and prevent traveler with near drowning
9. Diagnose, treat, refer, and prevent traveler with decompression syndrome after dive
CURRICULLUM CONTENT
1. Know and can perform immunization and give chemoprophylaxis to prevent travel-related
illness
a. Recognize the immunizations to prevent travel-related illness
b. Recognize the prophylaxis for malaria
2. Primary care practice for travel medicine
a. Understand the primary care practice specific for traveler
b. Recognize the management of primary care practice specific for traveler
3. Diagnose, treat, and prevent traveler`s diarrhea
a. Understand the definition of traveler`s diarrhea
b. Understand the etiology of traveler`s diarrhea
c. Describe the pathogenesis of traveler`s diarrhea
d. Recognize the clinical manifestation of traveler`s diarrhea
e. Recognize the management of traveler`s diarrhea
f. Understand the prevention of traveler`s diarrhea
4. Diagnose, treat, refer, and prevent DVT
a. Understand the predisposing factor of DVT
b. Describe the pathophysiology of DVT
c. Recognize the clinical presentation of DVT
d. Recognize the management of DVT
e. Understand the prevention of DVT
5. Diagnose, treat, refer, and prevent ACS
a. Understand the predisposing factor of ACS
b. Describe the pathophysiology of ACS
c. Recognize the clinical manifestation of ACS
d. Recognize the management of ACS
e. Understand the prevention of ACS
6. Manage traveler with respiratory disease who undergo air travel
a. Describe the flight environment
b. Recognize the physiological effects of exposure to altitude
c. Recognize the clinical pre-flight assessment
d. recognize fitness to flight condition
e. recognize respiratory disorders with potential complication for air travel
7. Diagnose, treat, refer, and prevent traveler heat exhaustion and heat stroke
a. Understand the definition of heat exhaustion and heat stroke
Udayana University Faculty of Medicine, DME
4
Study Guide
Special Topics
b. Describe the pathophysiology of heat exhaustion and heat stroke
c. Recognize the clinical manifestation of heat exhaustion and heat stroke
d. Recognize the complication of heat exhaustion and heat stroke
e. recognize the management of heat exhaustion and heat stroke
8. Diagnose, treat, refer, and prevent traveler with near drowning
a. Understand the definition of near drowning
b. Describe the pathogenesis of near drowning
c. Recognize the clinical manifestation of near drowning
d. Recognize the complication of near drowning
e. recognize the management of near drowning
9. Diagnose, treat, refer, and prevent traveler with decompression syndrome after dive
a. Understand the definition decompression syndrome after dive
b. Describe the pathogenesis decompression syndrome after dive
c. Recognize the clinical manifestation decompression syndrome after dive
d. Recognize the complication decompression syndrome after dive
e. recognize the management decompression syndrome after dive
10. Animal bite Objectives
a. To describe why rabies continues to be a feared zoonotic disease.
b. To describe how is rabies spread
c. To describe disease that Rabies most commonly mimic
d. To understand how Rabies is diagnosed
e. To describe the current recommendation for Rabies treatment
f. To describe pre and post exposure prophylaxis
g. To describe clinical presentation of Rabies
h. To describe the clinical management of snake bite envenoming
i. To describe the clinical management of scorpion sting envenoming
LEARNING TIME-TABLE
CLASS ROOM : 3TH FLOOR, ROOM A 3.01
No
Days
Topics
B Class
1
Friday
Oct.13th
2017
Emerging Diseases
Related Worldwide
Travelling
Udayana University Faculty of Medicine, DME
Time
A Class
08.00-08.30
09.00-09.30
Learning
Activity
Lecture
Place
PIC
Class
room
Dr.Made Agus
Hendrayana,M.
ked
5
Study Guide
Special Topics
08.30-09.00
09.30-10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
Traveler`s diarrhea
2
3
4
5
Monday
Oct.16th
2017
Tuesday
Oct.17th
2017
Wednesday
Oct.18th
2017
Thursday
Oct.19th
2017
Air travel: Acute
Coronary Syndrome
Air travel:
thromboembolism
General perspective
of Travel Medicine.
- Pre travel assement
- Post travel illness
High altitude
Udayana University Faculty of Medicine, DME
12.00-12.30
12.30 - 14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
12.30 -14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
12.30 -14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
08.00-09.00
09.00-10.00
Lecture
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
Lecture
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
Lecture
Class
room
Library
Disc.
Room
Class
room
Class
room
Dr.Made Susila
Utama,Sp.PD
Facilitators
Team
dr. Luh Oliva
Saraswati
Suastika,Sp.JP
Library
Disc.
Room
Class
room
Class
room
Facilitators
Team
DR.Dr.Ketut
Suega Sp.PDKHOM
Library
Disc.
Room
Class
room
Class
room
Facilitators
Team
Prof.Dr.dr. Tuti
Parwati, SpPDKPTI
09.00-10.30
12.00-13.30
Individual
learning
(IL)
Library
10.30-12.00
13.30-15.00
Small Group
Discussion
(SGD)
Disc.
Room
Facilitators
12.00-12.30
11.30-12.00
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
Class
room
Team
08.00- 08.30
09.00-09.30
Lecture
Class
room
Dr. I Putu
Adiartha
Griadhi,M.Fis
6
Study Guide
Special Topics
Air travel: respiratory
disease related travel
6
7
8
Friday
Oct.20th
2017
Monday
Oct.23th
2017
Tuesday
Oct.24th
2017
08.30 - 09.00
09.30 - 10.00
Lecture
Class
room
09.00-10.30
12.00-13.30
Library
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
08.00- 08.30
09.00-09.30
Lecture
08.30 - 09.00
09.30 - 10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
Near drowning
08.00- 08.30
09.00-09.30
Diving
Decompression
Syndrome
08.30 - 09.00
Heat exhaustion and
heat stroke
Air travel: Fit to Flight
Immunization to
prevent travel-related
illness
Chemoprophylaxis for
travel related illness
Udayana University Faculty of Medicine, DME
Disc.
Room
Class
room
Class
room
Class
room
Dr.I Gst.Ngr.
Bagus Artana,
Sp.PD
Facilitators
Team
Dr.Made Susila
Utama,Sp.PD
Dr.I Md.Ady
Wirawan,MPH,
PhD
Library
Disc.
Room
Facilitators
Class
room
Team
Lecture
Class
room
09.30 - 10.00
Lecture
Class
room
DR.Dr. Tjok
Senapathi,Sp.
An
Dr. Anita
Devi,M.Si
09.00-10.30
12.00-13.30
Library
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
Student
Project
14.00-15.00
15.00-16.00
Plenary
Class
room
Team
08.00 - 08.30
09.00-09.30
Lecture
Class
room
08.30 – 09.00
09.30 – 10.00
Lecture
Class
room
Dr. I K Agus
Somia, SpPDKPTI
Dr. I K Agus
Somia, SpPDKPTI
09.00-10.30
12.00-13.30
Individual
learning
(IL)
Library
Disc.
Room
Facilitators
7
Study Guide
Special Topics
9
10
12
13
Wednesday
Oct.25th
2017
Thursday
Oct.26th
2017
Friday
Oct.27th
2017
Monday
Oct.30th
2017
10.30-12.00
13.30-15.00
12.00-12.30
12.30 -14.00
11.30-12.00
10.00-11.30
14.00-15.00
15.00-16.00
Small
Group
Discussion
(SGD)
Break
Student
Project
Plenary
08.00-09.00
09.00-10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Student
Project
Plenary
Animal Bite
08.00- 08.30
09.00- 09.30
Lecture
Marine Envenomation
08.30 - 09.00
09.30 - 10.00
Lecture
09.00-10.30
12.00-13.30
10.30-12.00
13.30-15.00
12.00-12.30
11.30-12.00
Individual
learning
(IL)
Small
Group
Discussion
(SGD)
Break
12.30 -14.00
10.00-11.30
14.00-15.00
15.00-16.00
Medical evacuation
Student
Project
Plenary
Disc.
Room
Facilitators
Class
room
Class
room
Team
DR.Dr. Tjok
Senapathi,Sp.
An
Library
Disc.
Room
Class
room
Class
room
Class
room
Facilitators
Team
Dr.A.A Yuli
Gayatri,Sp.PD
Dr.Dewi Dian
Sukmawati,
Sp.PD
Library
Disc.
Room
Class
room
Facilitators
Team
Preparation for final
test
Assessment
Team
MEETING OF STUDENT REPRESENTATIVES
In the middle of block period a meeting is designed among the student representatives of
every small group discussion, facilitators, and source person of the block. The meeting
discuss about the ongoing teaching and learning process, quality of facilitators, and lecturers
as the feedback to improve the next process.
This meeting is held on Saturday when the students are free from lecture.
Udayana University Faculty of Medicine, DME
8
Study Guide
Special Topics
MEETING OF THE FACILITATORS
All facilitators are invited to discuss all block activities with block contributors 1 week after
meeting onf students representatives
ASSESMENT METHOD
Assessment will be held on end of the block period. The time provision is 100 minutes. The
number of MCQ is 100 with passing point ≥ 70
STUDENT PROJECT GROUPS AND TOPICS
BLOCK SPECIAL TOPIC TRAVEL MEDICINE SEMESTER 7
Udayana University Faculty of Medicine, DME
9
Study Guide
Special Topics
SGD
GROUP
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
SGD
GROUP
B1
B2
B3
B4
B5
B6
B7
B8
B9
B10
B11
B12
TOPIC
Supervisor Student
Project
Bug Bites
Jet Lag
Mental Health and Travel
Road Safety
Sex Tourism
Traveling with a Disability
Humanitarian Aid Workers
Last-Minute Travelers
Long-Term Travelers and Expatriates
Pregnant treveler
Elderly traveler
Travelling with children
TOPIC
Supervisor Student
Project
Travelers with Weakened Immune Systems
Travelers with Chronic Illnesses
Adventure Travel
Cruise Ship Travel
Medical Tourism
Travel to Cold Climates
Travel to Mass Gatherings
Fit to dive
Travel Health Insurance
Travel to altitude after diving
Hajj travel
Wilderness medicine
LEARNING PROGRAM
LECTURE 1
Emerging Diseases Related Worldwide Travelling
It is believed that increased global travel is the reason for the recent resurgence of many
infectious diseases in the world. International movement of individuals, populations, and
products is one of the major factors associated with the emergence and reemergence of
infectious diseases as the pace of global travel and commerce increases rapidly.
The number of people traveling internationally is increasing every year, and more people
are taking trips to remote parts of the world, which often have unfamiliar health problems
Udayana University Faculty of Medicine, DME
10
Study Guide
Special Topics
as well as underdeveloped health care services. Many travelers are also unaware of
potential hazards in different parts of the world and do not take the necessary
precautions, such as getting necessary vaccines or taking preventive medicine.
Travel can be associated with disease emergence because (1) the disease arises in an
area of heavy tourism, (2) tourists may be at heightened risk because of their activities, or
(3) because they can act as vectors to transport the agent to new areas.
Many of the newly discovered infections have actually been in existence for a long time,
but doctors have not seen them in areas where new outbreaks occur. With people's ability
today to travel anywhere in the world within 36 hours or less, formerly little-known
infections are picked up and rapidly spread to areas where they previously did not exist.
LECTURE 2
Traveler’s diarrhea
Traveler’s diarrhea (TD) is the most common travel-related health problem that affects up
to half of travelers during their first 2 weeks abroad. A case of TD is described as the
sudden onset of loose, watery stools associated with abdominal pain, fever or tenesmus.
Fever occurs commonly and blood is noted in stools rarely. Nausea and vomiting are
also common in the first few hours, adding to the discomfort and water loss. TD usually
presents as an acute illness, resolving completely in less than a week. Bacteria are the
most common cause of TD and ETEC (enterotoxigenic E. coli) is the most common
bacterial cause. Salmonella, Shigella and campylobacter make up the majority of
remaining bacterial pathogens. Host factors such as age, pre-existing immunity,
underlying medical conditions and genetic factors play a role in susceptibility to TD.
Effective pre-travel counseling may motivate some travelers to avoid risky food and
drink, which may in turn reduce diarrheal incidence. Since most TD is bacterial in origin,
traveling with appropriate antibiotics for treatment and prevention is also important.
LECTURE 3
Air travel and ACS
Cardiovascular events are the main cause of deaths among travelers and of in-flight
emergencies on commercial aircraft. Persons with underlying heart disease should review
their itineraries with a physician prior to departure; travel in harsh environments or to
remote destinations is not wise.
LECTURE 4
Air travel and thromoembolism
DVT and thromboembolism have long been proposed as possible complication of air
travel. Pulmonary embolism (PE) has been suggested as a culprit in deaths related to air
travel, although evidence linking air travel to DVT has been somewhat elusive. Many
studies found that 18% of sudden deaths among long distance travelers were attributable
to PE.
LECTURE 5
Udayana University Faculty of Medicine, DME
11
Study Guide
Special Topics
General perspective of Travel Medicine
Travel Medicine is the branch of medicine that deals with the prevention and management of
health problems of international travelers. It is concerned with both prevention and
management of illness related to travel
Why TM ?
• Increased trend of travelers : many more people are travel abroad
•
Scope has largely evolved in response to changing of travel trend, such as :
•
The reason for travel and types of travel has become much more diverse.
•
Organized package tour remain popular, but many traveler are becoming more
adventurous and choose to backpack out with ‘tourist‘ areas, go on expedition
into remote areas sometime in several countries and work as volunteers for
prolonged period.
•
Travel for business take a common place.
•
In addition, potentially vulnerable groups of people such as the very young, the
elderly, pregnant women and those with underlying medical problems or
disabilities and immune compromized are traveling more than ever before.
As a result of these changes, more people need information, more advise and more
prophylactic prior and during travel
Important component of TM includes not only vaccination and prophylaxis for malaria,
but also advise on accident prevention, sexual health and guidance on contraception,
safety food and water, hygiene and other precautions
History of TM ?
The disciplines of TM evolved initially from infectious disease, tropical and preventive
medicine and historically from quarantine and international health regulations, the
subject encompasses the whole range of clinical and preventive medicine; this
includes care of the travelers with special needs such as, children, the elderly,
pregnant women, and person with underlying medical problems: cardiovascular,
respiratory, kidney, GIT, metabolic , neurological, malignant, HIV and behavioral dis.
TM concerned with both prevention and management of illness related to travel
Illness may result from exposure to infection, accidents, psychological upset,
environmental hazards and political unrest
The specialty of TM therefore is truly interdisciplinary and international specialty
involving numerous disciplines including , tropical medicine, infectious diseases,
microbiology, public health and nursing.
Continued surveillance of illness and disease both in the host countries and returning
travelers is necessary to allow sound risk assessment to be made for intending
travelers. This is a crucial area for development within the specialty
Dissemination of information regarding real or potential risks can both prevent illness
and increase detection of illness in travelers who have returned to their country of
origin. This may have important public health implications when considering
secondary cases or outbreaks as a results of travelers returning with infections
Risks in Travel
Risk in travel can be non communicable and communicable disease
Non-Communicable disease :
• Aircraft travel, reduced O2, pressure and humidity
• Motion sickness
• Jet Lag
Udayana University Faculty of Medicine, DME
12
Study Guide
Special Topics
•
•
•
•
•
•
•
•
•
•
DVT’s and immobility
Altitude
Heat/cold/humidity
Sunburn
Water safety
Accidents and Injuries
Animals and Insects
Accidents, vehicles, marine
Snakes, (vipers, cobras and kraits )
Marine stings
There are many potential diseases spread via :
• Food and water
• Insect vectors
• Soil and water
• Sexual contact, Body-fluid exposures
• Animals
LECTURE 6
High altitude illness
High altitude medicine is one of medical science that discuss human adaptation that occur
in high altitude environment. It is importance for us to study this topic because some
people travelling to high area, expedition to the mountain, and excellent physiology
research in high altitude. Understanding human adaptation to high altitude provide us
importance information needed for planning the trip and avoid many disease that may
occur.
Aclimatization is the key point during high altitude travelling. Failure in this process will
affect our body condition manifest as several high altitude problems. Acute Mountain
Sickness (AMS) is the most common syndrome occur in high altitude, followed by high
altitude cerebral edema, and hipoxic hipoksia. As a medical doctor it is importance to
understand this topic, especially in region that choosen as traveller destination.
LECTURE 7
Air travel and respiratory disease related travel
For the vast majority commercial flights are safe, but a rising number are at risk of
respiratory complications triggered by hypoxemia, immobility and dehydration. Patients
with severe airways disease require assessment before flying. It is anticipated that these
patients will have already seen a respiratory specialist for their condition.
LECTURE 8
Heat exhaustion and heat stroke
Heatstroke (HS) is the most serious of the syndrome associated with excess body heat. It
is defined as condition in which body temperature is elevated to such level that body
tissue damage occurs, giving rise to a characteristic multiorgan clinical and pathological
syndrome. The severity depends on the degree of hyperthermia and its duration.
Heatstroke is a medical emergency that can be fatal if not diagnosed and treated
promptly. The literature differentiates between two entities of heatstroke: exertional
heatstroke (EHS) and classic heatstroke. The presentation of EHS is usually acute, the
prodorme, occurring in 25% of casualties, consists dizziness, weakness, nausea,
confusion, disorientation, drowsiness and irrational behavior, this may last from minutes to
Udayana University Faculty of Medicine, DME
13
Study Guide
Special Topics
hour. ES should be the working hypothesis in any cases of collapse during exercise or
immediately, apparently healthy individual whose body core temperature is high and who
presents with neurological sign (from aggressiveness to coma). Prolonged exertion, warm
climate, very high body core temperature and dry skin are typically linked with EHS.
Treatment of HS is supportive. Cooling should be initiated vigorously immediately upon
collapse. The most practical and efficient method of cooling is the use of large quantities
of tap water, which is readily available. No drug is effective in reducing body temperature.
LECTURE 9
Air travel and Fit to Fly
Each year, approximately 3.3 billion people are estimated to travel by aircraft.
Furthermore, the passenger numbers are expected to reach 7.3 billion by 2034, as
predicted by the International Air Transport Association (IATA). While many of these
people have medical conditions that pose no risk to themselves or to other passengers,
there are some medical conditions that should preclude flying or require pre-flight
evaluation.
Most airlines have medical passenger policies to determine fitness to fly, in order to
minimize the risk of disruption to other passengers and crew, the likelihood of the aircraft
diversion, and risks to the passenger’s safety. A passenger medical information form is
commonly used, which asks details from both patient and doctor, about diagnosis,
prognosis, desired supplemental oxygen, food, etc.
Reduced oxygen tension, pressure changes and reduced space and mobility are the
principal effects on the health of the air-traveler. Modern commercial airliners fly with a
cabin altitude of between 4000 and 8000 feet (1200 and 2400 m) when at cruising altitude
(30.000-39.000 feet), which means a reduction in ambient pressure of the order of 20%
compared with sea level and a consequent reduction in blood oxygen saturation of about
10%. The cabin air is relatively dry, and the limited room available in the non-premium
cabin may be a factor to be considered.
In determining the passenger’s fitness to fly, a basic knowledge of aviation physiology and
physics can be applied to the pathology. Any trapped gas will expand in volume by up to
30% during flight, and consideration must be given to the effects of the relative hypoxia
encountered at a cabin altitude of 8000 feet (2400 m) above mean sea level.
LECTURE 10
Near drowning
Traditionally, the terminology used to describe submersion injuries has been confusing
and impractical. In the past, drowning referred to death within 24 hours of suffocation from
submersion in a liquid, whereas near-drowning described victims who survived at least 24
hours past the initial event regardless of the outcome. In 2005, the World Health
Organization (WHO) published a new policy defining drowning in an attempt to clarify
documentation and better track submersion injuries worldwide.
Drowning was defined as “the process of experiencing respiratory impairment from
submersion/immersion in liquid.” Furthermore, the WHO policy states that “drowning
outcomes should be classified as: death, morbidity, and no morbidity. … Use of the terms
wet, dry, active, passive, silent, and secondary drowning should no longer be used.” As
such, the term near-drowning should not be used, and the association of the term
drowning with a fatal outcome should be abandoned.
Risk Factors
Ethanol consumption in proximity with water is a major risk factor for submersion injury or
death. Acute ethanol intoxication may be a contributing factor in 30 to 50% of drownings
among adults and adolescents.
Udayana University Faculty of Medicine, DME
14
Study Guide
Special Topics
In one study of boating fatalities, most of which were due to drowning, an association
between blood ethanol concentration and risk of death from drowning while using
watercraft was established Odds ratios of fatality from drowning followed a trend from 2.8
(95% confidence interval [CI] 1.6, 4.8) for a blood ethanol concentration (BEC) of 1 to 49
mg/dL to 37.4 (95% CI 16.8, 83.0) for a BEC of 150 mg/dL or greater compared with
sober case controls.
Pathophysiology
Unexpected submersion triggers breath-holding, panic, and a struggle to surface. Air
hunger and hypoxia develop, and the victim begins to swallow water. As breath-holding is
overcome, involuntary gasps result in aspiration The quantity of fluid aspirated, rather
than the composition, determines subsequent pulmonary derangement.
Sign & Symptom
Many submersion injuries are witnessed. Toddler drownings are an important exception,
however, often occurring because of a lapse in supervision. Occasionally, the history of
coughing, choking, or vomiting in a patient found near a body of water suggests the
diagnosis. Signs of pulmonary injury may be obvious in a submersion victim who is
hypoxic, cyanotic, and in obvious respiratory distress or arrest.
More subtle clues, such as increased respiratory rate and audible rhonchi, rales, or
wheezes, should alert the clinician to evolving respiratory compromise. Submersion
victims swallow a significantly greater volume of water than is aspirated, and gastric
distention from positive-pressure ventilation during rescue is common. As a result, 60% of
patients vomit after a submersion event. Aspiration of gastric contents greatly compounds
the degree of pulmonary injury and increases the likelihood that acute respiratory distress
syndrome will ensue. In addition, aspiration of particulate contaminants such as mud,
sewage, and bacteria may obstruct the smaller bronchi and bronchioles and greatly
increase the risk of infection both bacterial and fungal in nature.
Prognostic
Many factors may help predict patients who will survive a submersion injury neurologically
intact. Submersion victims who arrive in the emergency department alert with normal
hemodynamics are unlikely to experience neurologic impairment. Circumstantial variables
that portend a poor outcome include victim age younger than 3 years, submersion for
longer than 5 minutes, and initiation of cardiopulmonary resuscitation (CPR) more than 10
minutes after rescue. With the exception of victim age, however, such measurements are
generally either unknown or inaccurately estimated at the time of a patient's arrival in the
emergency department. Objective findings on emergency department arrival that are
associated with an unfavorable prognosis include hypothermia, severe acidosis,
unreactive pupils, a Glasgow Coma Scale score of 3, and asystole or the need for
ongoing CPR.
Neurologically intact survival is reported for individual patients even with several of these
factors present, and none of several proposed scoring systems using combinations of
these variables shows 100% predictive power
LECTURE 11
Diving decompression syndrome
Decompression syndrome is the most common consequence of diving activities.
Knowledge about this condition very important because of its different approach and
management.
LECTURE 12
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Immunization to prevent travel-related illness
Pre-travel immunization divide into three categories : recommended as part of routine
health maintenance irrespective of international travel; may be required into a country;
and recommended because of risk during travel.
LECTURE 13
Chemoprophylaxis for travel related illness (Malaria)
Malaria is one of the most severe infectious diseases of travelers. Nearly all cases in
travelers are preventable. Prevention and best management of malaria include
awareness of risk, avoidance of mosquito bites, compliance with chemoprophylaxis, and
prompt diagnosis in the event of a febrile illness either during or on return from travel.
LECTURE 14
Medical Evacuation
Transport pasien dalam keadaan kritis mempunyai resiko pada pasien sehingga
merupakan tantangan yang sangat besar bagi para klinisi. Alasan untukmelakukan
transport pada pasien adalah untuk mendapatkan pelayanankesehatan tambahan,
diagnostik atau terapiutik yang lebih canggih tidaktersedia.
Pasien dalam keadaan kritis memiliki sedikit atau tidak samasekali cadangan fisiologis
tubuhnya. Memindahkan pasien seperti tersebut menimbulkan suatu masalah tersendiri
dan dapat menimbulkan suatu perubahan fisiologis yang merugikan dan dapat
mengancam keselamatan pasien saat transportasi. Sehingga transport pasien kritis harus
dilakukan dengan persiapan yang matang dan perhatian yang seksama dan detail pada
hal-hal yang harus diperhatikan.
Guideline atau pedoman sudah tersedia dan prinsip-prinsip utama dalam melakukan
transport pasien kritis meliputi 5P:
1. Planning (perencanaan)
2. Personnel (jumlah yang cukup disertai dengan kemampuan yang sudah terstandarisir
dalam evakuasi pasien kritis).
3. Properties (alat yang dipakai dalam transportasi)
4. Procedures (alat yang dipakai mengukur kestabilan keadaan pasien sebelum dan saat
diberangkatkan)
5. Passage (pilihan rute dan tehnik transport).
LECTURE 15
Animal Bite
Rabies, Herpes B and envenoming are the diseases that result from bites by rabid
mammals or bites and stings by venomous animals, especially snakes and scorpions. In
all cases, appropriate early treatment, including therapeutic anti-sera, can prevent lifethreatening systemic spread of the virus or venom toxins.
Introduction
In recent years, the growth of the adventure travel market in particular eco-tourism,
extreme dive and wilderness safari has increased opportunities for travelers to encounter
dangerous species. For travelers to remote destinations pre-travel safety education
should be extended to include first aid for bite and sting injuries and potentially,
provisioning of standby antibiotics for prophylaxis of high-risk wounds
Mammals Bite or Scratch Wounds
Animal bites present a risk for rabies, herpes B, tetanus and other bacterial infections.
Animals’ saliva can be so heavily contaminated. Rabies is present on all continents with
the exception of Antartica, but more than 95% of human deaths occur in Asia and Africa.
Rabies occurs in more than 150 countries and territories. Worldwide, more than 55 000
people die of rabies every year, and 40 % of people who are bitten by suspect rabid
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animals are children under 15 years of age.. In travelers, bite wounds are mostly causes
by dogs (51%), monkeys (21%) and cats (8%). The wounds inflicted are often a
combination of punctures, avulsions, abrasions and crush injuries, the last of which may
not be apperent until compartment syndrome develops. Rabies virus, a rhabdovirus
present in infected animal’s saliva is inoculated into the bite wound, enter peripheral
nerves and spreads to the central nervous system where it causes a lethal
encephalomyelitis. Fortunately the availability of efficacious and save vaccines and
immunoglobulin has prevented many fatalities and almost 10 million people receive post
exposure treatment annually after potential rabies exposure, mostly following dogs bites.
In Addition, increase public and clinician awareness about the risk associated with an
injury from a macaque, improved first aid after exposure, the availability of better
diagnostic test, and improved antiviral therapeutics have decreased the case-fatality ratio
to 20% in treated people.
Before departure, travelers should have a current tetanus vaccination or documentation of
having received a booster vaccination within the previous 5-10 years. Travel health
provider should assess a traveler’s need for pre-exposure rabies immunization. In order
to prevent infection, all wounds should be promptly cleaned with soap and water, and the
wound promptly debrided, if necrotic tissue, dirt or other foreigner materials is present.
Travelers who might have been expose to rabies or Herpes B should contact a reliable
health care provider for advice about rabies or Herpes B post-exposure prophylaxis.
Snake bites
Snakebite accounts for the majority of severe envenoming in tropical developing
countries. Physicians with experience treating snakebite generally agree that while
elapids (cobra and kraits) account for the greatest number of deaths, vipers account for
the greates number of bites. Viper venoms is rich in enzymes, which cause local pain,
swelling, tissue damages, coagulopathy and for some species, damage to the kidneys,
adrenals and pituitary gland. Venom from cobras may be myonecrotic, leading to
devastating tissue injury; neurotoxic, leading to respiratory failure or possess mixed
activity. Poisonuos snakes are hazards in many locations, although deaths from
snakebites are rare. If snakebite result in intravenous injection of venom, syncope and
death may occur quickly. Deaths occurring within hours usually result from paralysis of
respiratory muscles following bites from kraits, mambas, coral snakes and Philippine
cobra. Death after 12 hours is likely to be caused by defibrination-related hemorrhage and
shock following viper bite. In developing regions, patients may suc-cumb days after the
bite, due to complications such as renal failure, secondary wound infection or failure of
mechanical ventilation due to power outages.
A large percentage of cobra and viper bites, between 25%-40% do not result in
envenoming and may be treated conservatively, while continuing to observe for delayed
onset of symptoms.
For extra precaution, when practical, travelers should wear heavy, ankle-high or higher
boots and long pants when walking outdoors in areas possibly inhabited by venomous
snakes. Travelers should be advised to seek immediate medical attention any time a bite
wound breaks the skin or when snake venom is injected into their eyes or mucous
membranes. Immobilization of the infected limb and application of a pressure bandage
that does not restrict blood flow are recommended first aid measures while the victim is
moved as quickly as possible to a medical facility. Specific anti-venoms are available for
some snakes in some areas, so trying to ascertain the species of snakes that bite the
victim may be critical.
Insect Bites and Scorpion Stings
Venom from insects can produce severe allergic reactions and lead to life-threatening
anaphylactic shock. More commonly, insect bites and stings are painful and produce local
reaction (redness and swelling) at the site.
The most medically significant venomous arthropods belong to order Hymenopthera
which include; bees, wasps and stinging ansts . Together the members of Hymenopthera
account for the greatest number of stings injuries and are responsible for considerable
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-
morbidity and in some case death secondary to hypersensitivity reaction. Most
Hymenopthera venom contains serotonin, histamine and in some tropical hornet species,
acetylcholine. The sting injuries cause immediate pain, which tends to decrease over min
30 in the case of honeybees (Apidae) or hours in the case of large hornets (Vespidae).
Honeybees have a barbed stinger. When the bee attempts to fly away, it is eviscerated,
leaving the stinger and the contracting venom gland behind. When present, the stinger
gland complex should be immediately removed with minimal regard to method, as even
minor delays will increase the amount of venom that is delifvered. Additional care;
washing with soap and water, verifying tetanus immunization and monitoring for infection.
Oral non-steroidal antiinflammatory agent (NSAIDs) such as ibuprofen are effective in
reducing pain, and swelling, but are little value after swelling is established. Oral
antihistamines are effective at reducing local pruritus which appears minutes to hours
after the sting injuriy. Cold pack relieve pain associated with Hymenopthera sting injuries.
Treatment of hypersensitivity reactions should be initated as soon as systemic symptoms
appear. The most effective therapy is prompt treatment with 1:1000 epinephrine
hydrochloride (0.25-0.5 ml, subcutaneous). Patients with severe reactions are likely to
need a second injection. Sting injuries that develop pain, erythema and lymphadenopathy
should be treated with antibiotics with activity against Gram positive skin flora.
Some spider species, such as the hobo spider (Tageneria) and violin spider group (violin
or recluse spider; Loxosceles) and several tipes of wolf spider (Lycosa) possess venom
capable of causing necrotic skin lesions. In the case of Loxosceles spider, necrosis may
be severe. Systemic effect of Loxosceles spiders include renal failure, hepatic
insufficiency and hemolysis. No FDA approved polyspecific antivenin is available for the
treatment of Loxosceles envenoming and treatment remains unsatisfying and supportive.
Widow spiders (Latrodectus) have a worldwide distribution and are responsible for a
significant number of neurotoxic envenoming. All widow spiders are a web-dwelling
species and it is a female spiders that are responsible for human bites. Widow spiders
prefer to build webs near attractant for insects such as trash dump, refuse pile and
latrines. Bites by widow spiders may initially be mild, however rapid onset of cramping
and muscular spasms cause considerable pain. Small children are at increased risk of
envenoming and a bad outcome. Highly effective antivenins against widow spider bites
are produced in Australia, South Africa and USA.
Scorpion are responsible for a significant number of fatalities in Central America, India,
and North Africa. Most fatalities involve small children and debilitated patients. Scorpion
venoms which are especially lethal in young children, release autonomic nervous system
mediators causing myocardial damage, cardiac arrhythmias, pulmonary edema, shock,
paralysis, muscle spasm and pancreatitis. Early administration of anti-venom is highly
effective, together with intensive care support in severe cases. In addition, infectious
diseases can be spread by insect bites, especially in tropical countries. Travelers are
likely to be envenomed when they take a shower and step on scorpions that have fallen in
to the tub. Many scorpions seek shelter in footwear or between folded clothing, leading to
unfortunate encounters. Antivenin is produced against several of the more toxic species
such as the Middle Eastern Leiurius and American Centruroides. In addition to antivenin ,
neorotoxic bites and stings may be treated with a compression bandage as for neurotoxic
snake venoming.
Wearing protective clothing, applying insect repellents containing DEET are important
preventive measures.
The general treatment include;
Ice or cold pack and sting relief swabs (applied topically) will help alleviate local pain and
swelling.
Any bite or sting can become infected and should therefore be examined at regular
intervals for progressive redness, swelling pain or pus drainage
Oral anti-histamines, such as diphenhydramine 25 to 50 mg every hours are helpful in
relieving the itching, rash and swelling associated with many insect bites and stings
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1.
2.
3.
4.
5.
6.
If anaphylactic shock occurs it must be treated immediately with epinephrine and
antihistamines.
A specifics antidote is available for those suffering severe symptoms
Reference
World Health Organisation. Rabies. Geneva: WHO, 2011. URL: http//www.who.int/ith
Susan E., Charles E., Daniel Fishbein, Cathleen A. Hanlon, Boonlert Lumlertdacha,
Marta Guerra, et al. Human Rabies Prevention --- United States, 2008. MMWR
Recommendations of the Advisory Committee on Immunization Practices. May 7, 2008 /
57(Early Release);1-26,28
World Health Organization. Rabies. Current strategies for human rabies pre and postexposure prophylaxis, September 2010
Meslin FX, Hemachuda T, Wilde H, Gongal G. WHO Standards for Rabies Control. At The
Occasion of the OIE Global Conference on Rabies Control: towards sustainable
prevention at the source, Incheon Republic of Korea 7-9 September 2011
WHO Guide for Rabies Pre and Post –exposure prophylaxis in Humans. Department of
Neglected Tropical Disease-Neglected Zoonotic Disease Team. Revised 15 Juni 2010
Weiss EA. A Comprehensive Guide to Wilderness and Travel Medicine. 3 rd ed. Adventure
Medical Kits, 2005: 121-133
LECTURE 16
Marine injuries and envenomations
Poisoning, envenomation, and direct trauma are all possible in the marine environment.
Ciguatera poisoning can result from ingestion of predatory fish that have accumulated
biotoxins. Symptoms can be gastrointestinal or neurologic, or mixed. Management is
mostly symptomatic. Scombroid poisoning results from ingestion of fish in which
histamine-like substances have developed because of improper refrigeration.
Gastrointestinal and systemic symptoms occur. Treatment is based on antihistamines.
Envenomations from jellyfish are painful but rarely deadly. Household vinegar deactivates
the nematocysts, and manual removal of tentacles is important. Treatment is
symptomatic. Heat immersion may help with the pain. Stingrays cause localized damage
and a typically severe envenomation. The venom is deactivated by heat. The stingray
spine, including the venom gland, typically is difficult to remove from the victim, and
radiographs may be necessary to localize the spine or fragment. Surgical débridement
occasionally is needed. Direct trauma can result from contact with marine creatures.
Hemorrhage and tissue damage occasionally are severe. Infections with organisms
unique to the marine environment are possible; antibiotic choices are based on location
and type of injury. Shark attacks, although rare, require immediate attention.
LEARNING TASK
LEARNING TASK 1
Emerging & Re-emerging Diseases
Related Worldwide Travelling
Case :
A family from Indonesia has plan a vacation to Hong Kong and China mainland next
week. They came to you to get some advices.
Learning Task:
1. Explain any diseases in Hong Kong and China mainland that needs to be alerted by
this family!
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2. Describe the each way transmission of that diseases!
3. Explain to that family the preventive measures so they can prevent the diseases!
4. How the SARS and AVIAN FLU Disease can spread worldwide?
5. Describe the transmission mode of Legionnaire’s disease!
6. Describe the relationship between the Tourism and Legionnaire’s disease!
7. Explain the mechanism of MERS-Cov spread from animals to infect humans through!
8. Explain how to prevent MERS-Cov infection!
9. Describe the clinical signs and symptoms of Ebola virus infection!
10. Explain the Ebola virus transmission!
Self-assessment:
1. What is the agent of Legionnaire’s disease?
2. What is their habitat?
3. Describe the clinical signs and symptoms of Legionnaire's disease!
4. Describe the clinical signs and symptoms of MERS-Cov infection!
5. What is the characteristic of Ebola virus?
LEARNING TASK 2
Traveler’s diarrhea
Learning Task :
Traveler group from Netherland come to emergency dept of private hospital with diarrhea
for 2 days, diarrhea more than 10 times for half day, stools without blood and slym, water
only. Nausea, vomiting and abdominal pain was found. They have history fast food dinner
in restaurant.
1. What is the possibility a cause of diarrhea in this ase?
2. How the management and treatment must you done in this case?
3. What is your suggest to travelers for prevention traveler diarrhea ?
Self Assessment
1. Describe etiology of Traveler’s Diarrhea
2. Describe pathogenesis of Traveler’s Diarrhea
3. Describe clinical pattern of Traveler’s Diarrhea
4. Plan for management of of Traveler’s Diarrhea
5. Describe complication
6. t may happen
7. Describe prevention of Traveler’s Diarrhea
LEARNING TASK 3
Air
Air travel
travel and
and Acute
Acute Coronary
Coronary
Syndrome
Syndrome (ACS)
(ACS)
Case :
A 55 years old man, British, fat, smoker, complain pain on his left chest, become worst and
feel difficult to breath. He just arrived in Denpasar after has 4 hours flight from Thailand.
Learning Task :
1. What other anamnesis should be added to this case?
2. What kind of physical examination should be focused for this patient ?
3. What kind of other supported examinations suggested for the patient ?
4. What is the possible diagnose for this case ?
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5. What kind of early emergency treatment you should do for the patient ?
Self assessment
1. Describe the predisposition factors for ACS related to the air travel !
2. Describe the trigers for ACS related to the air travel !
3. Describe the mechanism of ACS related to the air travel !
4. Describe how to prevent ACS during flight trip !
LEARNING TASK 4
Air travel and thromboembolism
Case :
A 55 years old man, American, fat, smoker, complain his left lower limb is swelling, painful,
cramp and pain on pressure. He just arrived in Denpasar after has 10 hours flight from United
States.
Learning Task:
1. What other anamnesis should be added to this case?
2. What kind of physical examination should be focused for this patient ?
3. What kind of other supported examinations suggested for the patient ?
4. What is the possible diagnose for this case ?
Self assessment :
1. Describe the predisposition factors for venous thromboembolism related to the air
travel
2. Describe the mechanism of venous thromboembolism related to the air travel
3. Describe how to prevent venous thromboembolism during long flight trip
LEARNING TASK 5
General
General perspective
perspective
of
of Travel
Travel Medicine
Medicine
Case:
A 28 year old woman from Swiss, come to you and ask your advise due to her plan to go to
Lovina to join a Yoga training program for 4 weeks
Learning Task :
1.
What ki