Dan Holmes / Anaesthetic Specialist / Royal Darwin Hospital, Australia
On Wednesday 13 November, for the first time ever, a full national Australian Medical Assistance Team (AusMAT), complete with a two-theatre field hospital, left from Darwin in the Northern Territory to offer humanitarian medical assistance after a devastating natural disaster. Five days previously, supertyphoon Haiyan had marched through the central Philippines, leaving in its wake a trail of apocalyptic destruction affecting over 11 million people. Dr Dan Holmes a Scottish anaesthetic consultant, now working in Darwin, was one of their number. (Photos by Dr Mark de Souza)
When does a typhoon become a ‘supertyphoon’? When the media decides that a little hyperbole improves the story? In fact in the United States, the JTWC (Joint Typhoon Warning Centre) uses the term on occasion. Was it a justified description of Haiyan, the 30th and penultimate named storm of the 2013 typhoon season though?
Let’s consider the facts. Haiyan is the fiercest storm ever recorded to have hit land. Sustained winds were recorded at 315 km/h, with gusts reaching 378 km/h. Over 6,000 dead and 1,700 missing make it the deadliest tropical cyclone ever to hit the world’s most cylone prone country. 600 km wide, with a negative pressure in its centre causing suction approaching that of a colossal vacuum cleaner, Haiyan sucked up the sea and hurled it on to land. The busy coastal city of Tacloban, along with its airport, sat under 6 metres of water.
Responding to Disaster
The resultant human suffering demanded a robust humanitarian response, with basics like water, food and shelter needed, along with medical care and repair to damaged infrastructure. The humanitarian response to sudden onset disasters can be well done by experienced organisations such as the International Committee of the Red Cross/Red Crescent (ICRC) and Medecins sans Frontieres (MSF).
As we know unfortunately, the response after the Haiti earthquake demonstrated to the world the other face of humanitarian work. On that occasion, hundreds of well meaning but untrained and poorly prepared individuals and teams descended on Port-au-Prince. On a general level that meant an additional burden on already disrupted infrastructure and the removal of precious resources from the very people who needed it most. If a load of rich foreigners were willing to pay $5 each for any available bottles of water, how could the locals possibly get any?
Specifically regarding medical care, unaccredited and unaccountable teams frequently performed ethically abhorrent procedures on injured people. A huge number of amputations, often guillotine, sometimes with no anaesthetic, imparted more physical and psychological distress on a vulnerable population. Guillotine amputations are extremely difficult to rehabilitate, even more so when the surgical team haven’t even considered the possibility of post operative complications or long term management. Furthermore, in some cultures amputees are treated as social outcasts, making any kind of meaningful or prolonged survival almost impossible.
The Australian Government set up AusMAT at the National Critical Care and Trauma Response Centre in Darwin in order to ensure that the surgical response from Australia after a catastrophe was appropriate. Specialist doctors, nurses, parmedics, pharmacists and logisticians are trained in a variety of fields (including disaster epidemiology, tropical disease, deployment readiness and cultural awareness). Those who wish to can then be placed on the AusMAT register and cannot be deployed unless they meet the full criteria, including being fully vaccinated and having the ability and resilience to cope in difficult, austere environments and work as members of a team.
Arriving in Tacloban
Arriving in a disaster zone is, from the outset, a pretty humbling experience. It certainly put a little perspective on debates over whether the children’s already bulging Christmas stocking could accommodate yet another lego set. We flew in to Tacloban airport, a handful of kilometres outside the city of 220,000 people which bore the brunt of Haiyan. The runway and control tower were by this point functional, but the rest of the airport was essentially destroyed. Aircraft taxi-tugs and baggage trolleys are a common sight on the tarmac, but I have never before seen them upside down and embedded in the terminal building.
The AusMAT field hospital was deployed beside the airport, a logistical decision based on the fact that at the time of arrival, there was no other area of land which could be cleared for a field hospital to sit. Nestled on a concrete slab between the runway and a flattened village, we could see a family sheltered under a tarpaulin slung over the branches of a fallen tree. The city smelled of death and waste, and debris and body bags lined the streets.
Post disaster healthcare follows well established patterns. The immediate trauma care has to be supplied by local services. If the local health system is devastated or overwhelmed then these early victims get a trial of life – in other words if you have severe injuries, you die. AusMAT were the first fully functional surgical foreign medical team in the region after Haiyan, but even then our first operation took place eight days after the typhoon struck.
Our hospital had 38 beds in 3 wards, 2 theatre tables (within one theatre) an emergency department and a 2 bed resuscitation room. We had x-ray capability but otherwise very limited investigative capacity, meaning a heavy reliance on old fashioned clinical evaluation.
The first procedures were most commonly typhoon-related wounds which, with the assistance of the storm surge acting like a tidal wave, had often become infected. An unexpectedly high burden of diabetes, frequently uncontrolled, made wounds even more difficult to treat, meaning some patients required repeated theatre trips. We performed only 6 amputations, all with anaesthesia and with the full consent of the patient and a rehabilitation plan in partnership with another NGO.
A dedicated theatre recovery was not available, and we had a relatively small number of beds for the number of procedures performed (up to 20 operations per day). Safety and throughput meant people needed to be awake quickly, protecting their own airway and mobilising so they could get home when their condition allowed. From an anaesthetic point of view this meant around 50% of cases getting spinal anaesthesia. Most of the rest were given a mixture of ketamine and propofol, titrated to achieve spontaneous breathing, good analgesia and a relatively quick wake up, whilst avoiding the patient movement and traumatic post-disaster hallucinations associated with ketamine alone.
The few true, first world style ‘general’ anaesthetics were reserved for cases such as strangulated hernias, depressed skull fractures, facial fractures and trauma laparotomies. General anaesthetics accounted for about 10% of our cases, and were done using a portable ‘drawover’ anaesthesia machine and oxygen concentrators. Drawover is taught on austere anaesthesia courses, but relatively few anaesthetists ever practice it in real life. Happily I can now further justify my own sporadic use of drawover anaesthesia at home, rather than simply using it to confuse the registrars.
As a post-disaster deployment wears on, presentations become less ‘disaster’ related and more about everyday medical issues in a developing country. Road trauma, hernias and abscesses all became the norm in theatre. Superimposed is the increase in infections as the standing water remains and the mosquito population rises. Tetanus (universally palliated), diarrhoeal illness, chest infections and dengue fever were all problematic during our time in Tacloban. And then, three days before our departure, there was a helicopter crash.
Receiving four multi-trauma victims at the same time into a tent hospital with few blood tests (we did have 3 units of O negative blood available, donated to us by the American military) was a true test of clinical acumen, teamwork and co-ordination. The victims were triaged, stabilised and managed by small pre-formed units of ED doctors and nurses, with the Anaesthetists and Surgeons assessing and helping out wherever necessary, whether using specialist skills or just helping lump the X-ray machine around. Despite some major injuries, all four victims survived and were either airlifted out to a city with more specialist services such as neurosurgeons, or operated on and stabilised in our facility.
It is rather a special thing to see and be part of a group of medical people working so well together so far out of their usual bubble of comfort. The fact that the AusMAT hospital was able to deal with 4 multiple trauma victims and either perform definitive care or arrange for rapid transfer to an appropriate Philippine facility, was testament to the work of the staff and to the relationship our leadership cell had been established with the Philippine military when arranging airlift of patients.
There were other interesting clinical challenges. I resuscitated, transfused and anaesthetised a young man shot in the abdomen using only basic monitoring and a manual blood pressure cuff. I transferred a critically hypoxic patient to another hospital in a minivan through a disaster zone in heavy traffic on the wrong side of the road with the oxygen cylinder running out. What could go wrong?
Life on the team
For my part as an anaesthetist however, the clinical involvement in such a deployment was not generally difficult. But it was hard work. We saw children die of malnutrition, adults die of tetanus and footling breech babies delivered stillborn. The days were long, and we slept in tents in the heat and humidity of the tropics with no fan (lest the frequent flooding of the tent from heavy rain create that heady mix of water and electricity). We ate a lot of stodgy rehydrated food. We lived at work, in each other pockets, spending every hour in the presence of colleagues. We built, cleaned, dismantled and packed up huge tents, mopped flooded floors, suffered prickly heat and caught the team virus.
Compared with the lot of the people of Tacloban however, dwelling on such things is small fry. Tales to tell for later, and to be put to the back of the mind beside thoughts of lego and Christmas stockings. The real question is, after 2,700 patients, 240 operations and 3 weeks of clinical work, did we actually do any real good? Did we do things accountably, ethically and properly? Did we justify the cost? As we continue to ponder, examine, discuss, analyse and work towards publishing our outcomes for public consumption (ensuring accountability and governance) I really think we did.
Note – two medical teams were deployed by AusMAT in succession. Team Alpha set up the field hospital and operated for 11 days. Team Bravo (of which I was a part) then took over and operated for a further 11 days and packed the hospital down. Each team had two surgeons (one orthopaedic and one general/trauma) and two anaesthetists with around nine other specialists, principally from ED.