Adapt, Improvise and Overcome
By A/Prof David Scott OAM
At around 7:30 in the morning on December 26, 2004, there was an undersea earthquake along the Andaman Islands fault. It was a magnitude 9.3 event, lasting for 600 seconds, making it one of the most powerful earthquakes in recorded history. As a result the ocean floor was thrust upwards, displacing 7.5 cubic miles of water (31,261 Gigalitres), causing a massive tsunami which spread east and west at 700km/hr.
At the northern tip of Sumatra Indonesia is the city of Banda Aceh (population 400,000) some 700 km from the epicentre. The earthquake shifted the northern tip of the island 3m west resulting in widespread, severe destruction throughout the city. While December 26th is a public holiday in Australia, it was a normal working day in Indonesia, so people were out and about at work, children and commuters were on busses, shopkeepers were opening up, people were going about their usual activities.
Once the earthquake stopped people sprang into action, commencing urban search and rescue for people trapped in collapsed buildings. The Indonesian army was mobilised to help search and provide support and hospital care. Some 30 minutes later, without warning, a series of tsunami waves struck the coast, the wave was estimated at 20m, travelling at high speed. The wave destroyed everything in its path for 2-3km inland, drowning tens of thousands, and leaving a trail of devastation.
It was into this situation that a surgical team (Combined Australian Surgical Team – Ache CASTA) made up of military and civilian trauma specialists (surgeons, anaesthetists, nurses) and public health doctors and nurses were deployed on December 28th, to provide humanitarian aid for the survivors of the disaster.
We met as a group at Richmond Airforce Base NSW on the 29th, were briefed as to our destination and loaded onto a RAAF Boeing 707 for a mission to Indonesia.
Prior to departure the estimated death toll was 28,000. By the time we came home the toll was 300,000 – the majority of these in northern Sumatra. Prior to this I didn’t know Banda Aceh existed, we were essentially deploying blind into a disaster zone, taking with us tentage, food and medical supplies to render aid to the survivors. Our destination was the airport at Banda Aceh, which had avoided significant damage.
How does one prepare for such a mission?
Although never clearly articulated, our mission was to render aid to the survivors of the tsunami in Indonesia, Sri Lanka, and other places. We really had no idea of the magnitude of the disaster, the likely injuries to expect, patient numbers or what ongoing care would look like. Under these circumstances it is not possible to mentally prepare. I knew it would be nothing like I had seen before, but we really had no clear idea what we were heading into.
I had deployed prior to this mission to Bougainville, Solomon Islands and East Timor on peace-keeping missions. The operational tempo for these missions was low, with few cases and plenty of quiet times. The missions were supplied with ADF equipment, which was basic but functional. Fortunately, this tempo allowed me to consider how to manage challenging cases with minimal equipment, and then at some level put that into practice – doing things like caesarean sections in tents with patients I couldn’t share a conversation with.
"We really had no idea of the magnitude of the disaster, the likely injuries to expect, patient numbers or what ongoing care would look like. Under these circumstances it is not possible to mentally prepare."
This is what I was expecting on this trip. What we had when we got there was the disaster medical kit prepared for the 2000 Olympics, which was cached in in Sydney. It had tents, and a range of emergency medical supplies. There were no monitors or anaesthesia machines, and a limited supply of drugs, airways, cannulas and other paraphernalia for anaesthesia and surgery. All of this we discovered when we unloaded the 12 tonnes of supplies by hand onto the airfield at BA after sunset on December 30th. The next day we (relying on military intelligence) moved into an abandoned private hospital in the city and commenced operations.
In a situation like this the key consideration is not to focus on what you don’t have, but on what you do have, and how you can use it to achieve your objectives. If unable to achieve all goals, then consider what you can do with what you have, and make sure this plan is socialised with the team, so that should you encounter a problem you lack the capability to deal with you can take a conservative approach to. For example, respiratory failure due to pneumonia was treated with supplemental oxygen and antibiotics empirically. Ventilation was not an option, and as a result, several of our patients succumbed to pneumonia, who would have at the very least been ventilated in ICU back home.
Tough decisions like that need to be made prior to encountering the patient, and with the concurrence of all carers. If not, the dissent can be very destructive to morale.
"In a situation like this the key consideration is not to focus on what you don’t have, but on what you do have, and how you can use it to achieve your objectives."
The team for this mission was drawn together rapidly, fortunately the anaesthetists all knew each other and were in the military. I also knew some of the surgeons, but few of the others. Typically, in a mission like this there has been team training, mission rehearsals, careful consideration of team members, and familiarity with the equipment deployed. CASTA had none of this, however the experience and training of the military personnel formed a nucleus which others gathered around, and the team naturally coalesced.
There were four anaesthetists and we divided into 2 groups to work as teams. There were no anaesthesia assistants, so we helped and supported each other. In order to facilitate this we deliberately set up two operating tables in the one large operating room (which had the best light and ventilation) and worked together looking after two patients at a time. This mutual support was so helpful for managing difficult situations and allowing breaks without holding up life saving surgery.
As we were supplied with very basic equipment and drugs, most of our surgery was conducted with TIVA using intermittent boluses of ketamine, midazolam and spontaneous breathing room air, with judicious additional oxygen were needed as indicated by saturations less than 92%. Opiates were minimised due to the respiratory depression they caused, and the lack of the ability to assist ventilation.
Recovery was rudimentary, a quiet, dark room with one person to ensure patients were breathing until they regained consciousness, and then returned to the ward. This process went on for 9 days until we were relieved. During our time there we completed 108 surgical operations including 17 major limb amputations for profoundly infected lower limb compound fractures. We experienced two perioperative deaths, both due to blood loss, with no capacity to transfuse.
After 10 very hectic and challenging days where we had multiple after-shocks up to 7.3 on the scale, random gunfire from traumatised Indonesian soldiers, constant threat of infection, stench of death, all on the background of equatorial heat and humidity we were relieved and sent home. A flight in a RAAF Hercules to Jakarta, a night at a posh hotel with a brief ‘debrief’ , and home on commercial flight to Sydney the next day, some of us were met by family in Sydney, others took subsequent flights back home to a ‘normal’ life.
PTSD is a term used commonly today for people who have difficulty adjusting from trauma. It is not possible to experience the devastation and human tragedy of that time and place without being emotionally impacted. I found I had PTSD after this, but it took some time to manifest. That is something you can hear about on the ANZCA Oral history website.
We arrived to Banda Aceh with limited kit, but with experienced and adaptable personnel, and we applied the axiom of adapt, improvise and overcome. Every operation was life-saving and every life saved was worth it.
A/Prof David Scott OAM is an Anaesthetist at Lismore Base Hospital, a Reservist in the Royal Australian Air Force and a Past President of the Australian Society of Anaesthetists. He was awarded the national honour of an Order of Australia Medal (OAM) earlier this year for service to medicine and anaesthesia.