“Many disciplines on an island”

7th National Allied Health Conference 2007

No discipline is an island

Allied Health participation in an Australian Medical Assistance Team in Java

- the pharmacist’s perspective

tion: Yogyakartapronounced “Jogjakarrrrta”

located in central Java

active volcano (Merapi) to nor

Borobudur to northwest

(Bhuddist holy place, World H

Bantul region (many small villa

and Indonesian sea to south

Dr Julie McMorrow

Critical Care PharmacistRoyal Perth Hospital

and

Health LogisticianAustralian Medical Assistance Team (WA)

Primary Care / Public Health Mission Yogyakarta, June 2006

Civilian medical assistance teams

� first deployed post-tsunami in 2004/05

� small teams, specialised but with broad experience

� multiple roles

� disaster response training

� exchange of information, goodwill

� other countries prefer civilians over troops

� Australian Defence Force not sent to Jogja

Australian Medical Assistance Teams (AMATs)

Team Alpha� May 31 - June 14

� acute surgical mission

� NSW/ACT hospital, CareFlight, Urban Search And Rescue personnel, AusAID and EMA liaison (total 27 members)

� “first team in” has the hardest job!

� 4-10 surgeries per day @ TNI field hospital in sports stadium

� worked with Ludeira + Bethesda Hospitals

� interrupted by volcano evacuation alert Thurs 8th June

� we “inherited” their cache (surgical equipment, drugs, supplies)

Australian Medical Assistance Teams (AMATs)

� Team Bravo (that was us!)� June 12-26

� first night/day: handover from Alpha Team, establishing relationships with local organisations

� primary care / rehabilitation / public health mission

� WA hospital, GP, public health and FESA personnel, AusAID and EMA liaison (total 14 members)

� first time Allied Health included (physio + pharmacist)

� handed over patients and cache before departure

AMAT-WA (Team Bravo)� Doctors:

Andy Robertson (State Health Disaster Management Coordinator; Team Leader)

Mark Little (ED/Tox/SOS retrieval), Helen Mead (ED/Paediatrician),Judith Findlay (GP/Red Cross), Charles Douglas (Public Health, Kalgoorlie)

� Nurses: Muriel Leclercq (ED/Remote Area/Disaster Management; Deputy Team Leader),

Angie Jackson (ED/midwife/SOS retrieval); Megan Scully (Public Health)

� Physiotherapist: Nick Buttigieg

� Logistics: Lloyd Bailey and Rik Lieftink (FESA logisticians)

� Health Logistics: Julie McMorrow (critical care pharmacist)

� Liaison: Katherine Mitchell (AusAID); Malcolm Purcell (EMA)

AMAT Bravo, Yogyakarta, June 2006

Logistics: what’s involved?� “the art of moving, housing, supplying and maintaining”

a team of people

� military, emergency services & health carelogistics combine in disaster preparedness and response

� “disaster cache” = supplies, equipment, drugs (and information!)

� pharmacist logistics experience

� “quantity surveying”, stock control, troubleshooting

� emergency medicine, intensive care, primary care, paediatrics

� infectious diseases / other public health issues

� Bali bombings, plane crashes, industrial explosions

� tsunami response & team support

FESA logistician roles: overview� planning, packing, transport & storage

� safety briefings, emergency equipment & evacuation

� assistance with medical equipment, drugs & supplies

� liaison and communication

� power and lighting

� village clinic setups

� cultural liaison, local meals

� lots more!

Health logistician roles � supplies, drugs, equipment (with Team assistance)

� planning, ordering, packing, transport, storage

� stock retrieval, issues, recording

� handover from Team Alpha medical logistician

� prior to departure and in Jogja

� drugs and vaccines; incl. “cold chain” and security issues

� bulk IV and irrigation fluids

� medical and surgical supplies and consumables

� medical and surgical equipment and power sources

� merging of cache: Alpha / other with Bravo

Health logistician roles � team personal care drugs, “crash packs”

� “refrigerate” and schedule 8 medications

� drug usage and safety information� paediatric drug dosing pocketbooks

� Therapeutic Guidelines: Antibiotic, Cardiovascular

� verbal advice, reminder tags on stock

� child safety reminders (secure village clinic drug storage)

� village clinic setups

� assistance with clinic dispensing

� clinical advice to health authorities � on request, via Team Leader and AusAID

� appropriate donation of unused cache items

Pre-departure timeline� June 1 (Thurs late): first notification

� deployed earlier to work on drugs/fluids/supplies lists

� June 2-5: at ED Pharmacists’ Seminar, Sydney

� first 8 vaccinations “on the way to the airport”

� obtained mobile no. for Team Alpha medical logistician

� ordered paediatric pocketbooks, antibiotic guidelines

� June 6-7: passport, consultation/drug lists/ordering,

liaison with AusAID re: Indonesian tetanus treatment

� June 8: packed cache (3.5 tonnes, 5-8 people)

� June 9: pre-departure briefing day; surgical team stood down

� June 10-11: team drugs, personal preparations, departure

Packing cache: DHL warehouse, Perth Airport 8th June

Pre-departure “incidentals”� AusAID “FYI” email cc’d Wed 7th June

� Indonesia requesting only IM tetanus immunoglobulin• IM (250 units per vial) for dirty wound prophylaxis only

� aware of need to anticipate actual tetanus cases• need 4000 units IV per case• 16 injections x 250 units IM into tetanic muscle very

painful, less effective

� advised AusAID (Red Cross Haematologist/CSL backup)• one case confirmed already (85yo male: fatal)• AusAID procured all surplus Australian IV TIG

� outcome• 105 x 4000 units IV sent urgently with AusAID escort• changed Indonesian tetanus treatment protocols

Pre-departure “incidentals”� Visa hassles Fri 9th June

� Team Leader / AusAID / EMA Liaison continued negotiations during briefing day

� Indonesian Consulate finally approved visas, but requested additional passport photos

• afternoon of Muslim Holy Day = little time • Monday = public holiday in Canberra

� logistics intervention: “phoned a friend”• Head of RPH Medical Illustrations Dept • had photographer sent to briefing• visas through just in time

Customs clearances� us? no problems - arrived Mon 12th June pm

� our airfreighted supplies? - delayed until Wed am

� what about the “refrigerate” drugs?

� cold packed by RPH Pharmacy Store Fri 9th June

� knew “good for 3 days” BUT had planned for delays:

had “out of fridge” stability data with me

� all items OK >> 48hours: NO WORRIES !

� time-consuming/impractical to replace stock

� “prophylaxis of angst” = important pharmacist role

Yogyakarta (pronounced “Jogjakarrrrta”)

� official language Bahasa Indonesia � villagers / older people: Javanese dialects, even Dutch

� “polite” words in Bahasa and Javanese: enough to get by

� with patients, useful to know:• body parts• “pain”, “diarrhoea”, “infection” words• “are you sleeping OK?”• “time” and “quantity” words

� medicine directions written opposite way to ours (“ 3 / ½”)

� our interpreters were fantastic !

Yogyakarta Earthquake

� Sat 27th May 2006

@ 0554am

� epicentre in Bantul region,

south of Yogyakarta

� preceded by eruption of

Mt Merapi since 8th May

� serious eruptions every 10-15 years

� extremely catastrophic eruption in 1006 !

2006 earthquake

� at least 5800 dead

2006 earthquake� over 30,000 injured

� typical story - “house shook for 30 seconds, then fell on me”

� worsening of pre-earthquake injuries:

people with broken legs and hips had to run away

� all wounds had to be considered tetanus-prone

� up to 600,000 homes destroyed / uninhabitable

� mainly in Bantul, Klaten, Jogja districts

� 80-100% of homes destroyed in many villages

� approx 30% severely damaged in Jogja city area

� over 1.5 million people homeless?

Hospitals overwhelmed� Sardjito Hospital = the “Royal Perth” of Jogja

� normally 750 beds

� 3300 patients late May

� 450 earthquake inpatients late June (4 weeks)

� most outside on footpaths during first week

� overcrowding, fear of aftershocks

� many discharged with “follow-up in 3 months”

� found in villages by Team Bravo

� some unable to walk

� families not sure what to do

Hospitals overwhelmed� 10-bed ICU at Sardjito, but:

� 50 patients with severe sepsis @ 14th June

� resistant Pseudomonas, Klebsiella

� lack of suitable IV antibiotics

� “100 patients needing albumin”

� Medical Director requested assistance via AusAID

? how would we cope in a similar situation ?

Assistance provided to Sardjito� antimicrobial therapy advice to Medical Director

� based on experience post Bali bombings (RPH 2002-2003)

� likely “bugs” involved and susceptibilities (later confirmed)

� antimicrobial agent selection

� dosing guidelines (with adjustments for renal dysfunction)

� literature references (via internet/faxed from RPH)

� RPH infectious Diseases backup

� my copy of Sanford! (antimicrobial therapy pocketbook)

� urgent airfreight arranged by AusAID� meropenem injection

� albumin 25% (for selected patients only!)

“Non-mission” assistance� primary care / public health mission,

BUT hospitals overwhelmed, requesting assistance

� in future, if requested, a small “hospital team”

(eg: ID Physician, Intensivist, Clinical Pharmacist)

could provide strategic support to local Specialists

� Team Leader “triages” requests

� considers clinical, political, practical and cost issues

� refers to appropriate agencies / team members

Post-earthquake problems� food shortages

� people: first 2-3 weeks � domestic animals and birds

� water supply� contamination� drops in well levels (as much as 90 metres!)� broken or melted water pipes (volcanic ash)

� accidents� rebuilding, falling debris� compromised living conditions, eg: burns & scalds

village water supplies disruptedby earthquake,significantdrop in well water levels

Post-earthquake problems� tetanus

� low vaccination rates (20% overall?)

� injuries during earthquake

� altered living conditions

� rebuilding accidents

� 73 reported cases by late June

� 38% case-fatality rate

Post-earthquake problems� other infectious diseases

� diarrhoea

� measles

� typhoid

� scabies

� respiratory tract

infections

� avian influenza

education & vigilance

possible volcanic eruption danger areas

Team Alpha

transported cache

to and from

TNI field hospital

in sports stadium

each day

Team Bravo: post-arrival briefing Mon 12th June

AMAT Alpha cache handover in Jogja

Muhammadiyah Tues 13th July

Assembling team “crash packs”

Merapi’s moods: changes over 5 minutes

“Room 552 cache”� drugs needing extra security

� medical equipment (if to be kept charged)

� “refrigerate” and “store cool” drugs

� freezer bricks x 60! � rotated through different parts of fridge/freezer

� thermostat kept at 5�C� maintained actual room temp at 18�C

� helped keep fridge temperatures @ 2-8�C

� slept in a jumper

benzodiazepinesstorage

Cache drugs sorted by therapeutic category for ease of retrieval

Picking stock for clinics

Morning logistics briefing

Local health centre:

“moderately affected”

village, Bantul

Setting up a village clinic

� Organise stock in advance

� Meet with officials to identify potential site

� Meet with Head Man of village, landowner

� Clear site

� Set up tent and stock

� Advertise (“gratis” was usually sufficient!)

� See patients

Local medicines packaging & labelling� bulk oral medicines in large bottles

� usual pack size = 500 tablets• cheaper, but contamination / mixup / overdose hazards

� English, American or Latin drug names• some familiar• some unfamiliar

to Australian doctors and nurses

� some “problem” strengths or ingedients• dextromethorphan 15mg

(Australian products = 5mg per dose) • paracetamol with caffeine

Local medicines packaging & labelling

� patient “take-home” medicines

� small quantities, eg: 1-2 days of an analgesic

� zip-lock plastic bags

• no dispensing label

• not everyone could read

• brief directions written onto plastic in ballpoint pen

• eg: “ 3 / ½” (take HALF a tablet three times daily)

• we used indelible felt-tip pen (easier to read)

Clinic safety � considerations:

� local people are small, not used to effects of medicines• use lower doses• short courses, then review

� establish safe dispensing, checking and recordkeeping systems

� ensure treatment is sustainable / able to be monitored adequately

� identify items/procedures for use by AMAT only

� identify any items not to be left overnight in clinics

� keep all medicines, disinfectants, etc. out of reach of children; warn village elders to keep children away

� avoid drinking cordial in front of children

� safe disposal of sharps, medical waste, unwanted medicines

before we introducedsharpscontainers!

Prevention of “disaster under plaster”

Stress management and education- by psychologists, midwives and public health stafffrom combined AMAT-WA, SOS and Muhammadiyah teams

� sleep disorders

� art therapy for children

� women’s clinics

� infant feeding

� immunisation

� diarrhoea prevention

� contraception

� sexually-transmitted infections

� avian influenza awareness

Evening reports: clinic teams, rehab, public health

Team room:reports,meetings,emails home!

What Team Bravo did…� set up 7 village clinics in Bantul and Klaten

� saw nearly 1800 patients (10 full + 2 half days)

� arranged patient follow-up

� evacuated patients needing hospitalisation

� provided rehab reviews, mobility aids

� immunised 730 people (mainly tetanus, also measles)

� provided village education sessions,

using local health care workers (very entertaining!)

What Team Bravo did…� worked with Indonesian SOS and Muhammadiyah

doctors, nurse midwives, nurse paramedics, physios,

psychologists, pharmacists, others

� provided critical drugs and information to Sardjito Hospital

� donated and delivered remaining cache before departure:

equipment, unused drugs, IV fluids and supplies

� provided copies of treatment records to patients,

local and government health offices, WHO

� handed over patients and clinics to SOS / Muhammadiyah

Allocation and packing of

unused cache

for pre-departure

donation

to Sardjito and

Muhammadiyah’s hospitals;

vaccines went to

Provincial Health Office

home:

“did all thatreally happen…

…or did we just

dream it all?

Things for next time: cache� In Perth: pack by therapeutic categories

� Compile a “disaster formulary”

� rationale for inclusion of each item in cache

� possible substitutes if stock not available

� supporting info / precautions for drugs + supplies

� Treat consumables + equipment like drugs

� use generic as well as common names (what’s a “diagnostic set”?)

� no-one “rearranges” the stock except logistics staff!

� record quantities issued manually, update at night if possible

Things for next time: record-keeping� Pre-printed picking lists with blank columns

� suitable for “pen & paper” use if no computer access

� daily orders versus daily issues

� notes and adjustments

� provision for additions: new items, other caches

� easy generation of “donations lists”

� stock levels: at start, daily balances, at finish

� bring hard copies (1 per day) in case no printer / copier

� Laptop� bring own (1 per logistician?)

� internet access / email useful if available

Things for next time: “cold chain” considerations� Fridge / freezer

� supplying our own next time?

� include cooler bricks (approx 40?)

� temperature monitors for different areas

� Smaller portable coolers (“Eskies”)

� 2 per treatment team: for clinic + “walkabouts”

� temperature monitoring themometer for each

� fewer cooler bricks needed if smaller• less dead space • less weight (occupational safety issue)

In conclusion…� Inclusion of a pharmacist as health logistician

� assisted FESA logistics staff, who were less familiar with health

terminology and equipment

� freed doctors and nurses to spend more time with patients

� prevented unnecessary reordering of “refrigerate” products

� Increased familiarity with surgical supplies and equipment,

Indonesian product knowledge and prescribing practices will be of

benefit in future deployments

� Working with a multidisciplinary team to assist the people of

Java was challenging, but very rewarding

AMAT-WA thanks…� our translators:

� Ririn, Fitri, Widi, Deborah, Bastian, Anton

� Nathan and the gang from HK Shipping

� drivers, security guards, local work crews

� hotel staff

� local officials: Muhammadiyah, village elders

� landowners, villagers who cleared clinic sites

�everyone at home !

Our hard-working and multi-talented Translators: Fitri, Deborah, Bastian, Anton, Ririn and Widi

Disaster Preparedness and Management Unit Staffwho looked after us whilst we were away...

Photography: M Bundhowi (“Bun”)

AMAT Team members