Responding to the Boxing Day tsunami disaster in Aceh, Indonesia: Western and South Australian...

Emergency Medicine Australasia

(2006)

18

, 86–92 doi: 10.1111/j.1742-6723.2006.00810.x

© 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Blackwell Publishing AsiaMelbourne, AustraliaEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty Ltd20061818692Xxxx Xxxx

Response to tsunami disaster in AcehA Pearce

et al.

Correspondence: Dr Chris Curry, Emergency Department, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia. Email: [email protected]

Andrew Pearce, FACEM, Emergency Physician, Trauma and Retrieval Consultant, Wing Commander, RAAF Specialist Reserves; Paul Mark,FACEM, Executive Director Medical Services, Clinical Senior Lecturer Emergency Medicine; Norman Gray, FACEM, Emergency Physician,Major, Army Specialist Reserves; Chris Curry, FACEM, Emergency Physician, Clinical Associate Professor Emergency Medicine, Chair ofInternational Emergency Medicine Special Interest Group of ACEM.

P

ERSPECTIVES

Responding to the Boxing Day tsunami disaster in Aceh, Indonesia: Western and South Australian contributions

Andrew Pearce,

1

Paul Mark,

2,3,4

Norman Gray

5

and Chris Curry

3,4,6

1

Royal Adelaide Hospital, Adelaide, South Australia,

2

South Metropolitan Area Health Service, Perth, Western Australia,

3

Fremantle Hospital, Fremantle,

4

Emergency Medicine, University of Western Australia, Perth,

5

Fremantle Hospital, Fremantle and Rockingham and Kwinana District Hospital, Rockingham, Western Australia,

6

International Emergency Medicine Special Interest Group of ACEM, Melbourne,

Victoria, Australia

Abstract

Objective:

To describe the Western and South Australian response to the Boxing Day tsunamidisaster in Aceh, Indonesia.

Method:

Reports from three of the responders.

Results:

Comment has been made on organising a response, the first team to Banda Aceh, thesecond team to Banda Aceh, and lessons learned.

Conclusions:

These experiences have identified areas in which we could be better prepared for the nextinternational disaster response.

Key words:

Aceh Indonesia

,

disaster response

,

international emergency medicine

,

tsunami

.

Introduction

The tsunami struck on Boxing Day, 2004, at the peakof the Australian summer holiday season. At the timethere was no formalized process for a comprehensiveresponse to a disaster of such magnitude in a neigh-bouring region. The established agencies for interna-tional aid and for national, state and local disasterresponses were therefore called upon to organize a

response. These included the Australian Agency forInternational Development (AusAID), AustralianHealth Disaster Management Policy Committee (AHD-MPC), Emergency Management Australia (EMA), StateHealth Disaster Management Committees (SHDMC),State Departments of Health and hospital managers.Also involved were the Commonwealth Department ofForeign Affairs and Trade and the Australian DefenceForce (ADF).

Response to tsunami disaster in Aceh


87

The present paper presents the perspectives of threeemergency physicians (EP) from Western Australia(WA) and South Australia (SA) who responded to thedisaster. Paul Mark is Executive Director of MedicalServices for the South Metropolitan Area HealthService at Fremantle Hospital in WA. His accountillustrates the ‘doing it on the run’ organization of theresponse. Norman Gray, EP and Army reservist, was amember of the first team to be dispatched. He reportson the Combined Australian Surgical Team Aceh(CASTA) mission. Andrew Pearce, EP and RoyalAustralian Air Force (RAAF) reservist, joined TeamEcho from SA in the second deployment to BandaAceh. He focuses on the uncertainties of the missionand on lessons that can be learned. These experienceshave identified areas in which we could be better pre-pared for the next event.

Organizing a response

Paul Mark

I was watching the Foxtel News when the tsunami wasfirst reported. The description of the event seemedmassive, yet the number of casualties mercifullysmall. Over time, of course, those numbers increaseddramatically.

A day later I had a call from Dr Andy Robertson, theDirector of Disaster Preparedness and Management inWA. He had been asked by the Commonwealth to pro-vide a medical team for dispatch at 22:00 hours thatnight. We needed people with military or overseas aidexperience, with current passports, who were fit, pref-erably vaccinated at least against hepatitis B and teta-nus, and who were prepared to work in a dirty andharsh environment for some 10 days. We needed medi-cal and nursing staff from emergency medicine, operat-ing rooms, general surgery and orthopaedics as well assomebody to manage logistics.

So the task began of ringing around my colleaguesthroughout the hospital to see who was available. Iasked a senior nurse to do the same for nursing staff.We both had a good idea who we should ask, peoplewith the essential characteristics of good teamworkersand calm under pressure. All those asked agreed with-out hesitation, which was encouraging, given the shorttime frame to departure and the uncertainties in whatlay ahead. Our staff members departed that night andwere subsequently deployed to Banda Aceh and theMaldives. I was grateful for the considerable number of

colleagues who came forward in the following days andwe could easily have sent further staff if we had beenasked.

Andy Robertson decided to lead one of the teams andso I was asked to act as State Health Coordinator. Thefirst task was to call a meeting of the SHDMC and tosupplement the standard membership with people withthe knowledge and skills for this type of incident. Ini-tially the focus was on trauma, but it was clear fromthe outset that there would be many other emergingissues.

Despite the Christmas break most of the relevantpeople were able to attend. I was provided with briefingnotes on various issues including environmental health,public health and mental health. Further meetingsof the SHDMC were held to review our progressand to refine our planning at Department of Healthlevel, particularly as the need for further teams wasdiscussed.

I participated daily in the AHD-MPC teleconfer-ences. These included the Chief Health Officers fromall the Australian jurisdictions and were very construc-tive meetings. They included a summary of the dailybriefing from the Department of Foreign Affairs andTrade, reports from our teams on the ground andfrom the ADF, and discussion of those issues that hadreceived media attention. The AHD-MPC ensuredcollaboration between jurisdictions and a commonapproach to contentious issues. It also allowed us toschedule further teams if they were to be requestedand to exchange information that had been learnt fromthe first deployments. Also involved was the Directorof EMA – the major logistics organization for deploy-ment of Australian responses around the nation andoverseas. EMA is well known for its educational role indisasters. It played a pivotal role in Australia’s tsu-nami response.

There were only a few issues that threatened tobecome controversial, such as whether volunteersshould be encouraged to go-it-alone to the affectedareas. Infrastructure had been severely damaged, trans-port was very limited, the airports in places such asBanda Aceh were working beyond their normal capac-ity and there were some security concerns. Althoughvolunteers were all well-meaning, our advice was theyshould participate as part of the AusAID effort or withone of the recognized non-government organizations.AusAID was the federal umbrella under which the juris-dictional medical teams were deployed. All the teamshad to be self-sufficient for food, water and other dailyliving requirements.

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In the early days it seemed highly likely that WAwould be asked to provide a further team for deploy-ment. Considerable work was undertaken to prepare forthis including the development of recommended lists ofpersonal equipment and definition of what medicalequipment could and should be taken with the teams.The largest task however, was sourcing all of the sus-tenance requirements including food, water, shelter andother items that a team of 20 people would need to beself-sufficient for a period of up to 2 weeks in a harshenvironment.

The selection criteria for volunteers became morestringent over time and we developed a database torecord consistent information. Fluency in a relevant lan-guage became more important, as did skills in publicand environmental health and primary care. The WADepartment of Health had set up a volunteer linethrough its

Health Direct

service. There was also anational line, and we kept the two coordinated by send-ing each other daily updates.

In all, more than a thousand health workers in WAvolunteered their help. AHD-MPC rotated the subse-quent teams on a jurisdictional basis, but called a haltto the deployments before WA was asked for a furtherteam. By that time there were substantial assets fromthe ADF in the area, and representatives from a largenumber of countries.

There were many other issues to address, including:• Ensuring that adequate insurance was in place for

the staff we had deployed, and that they continuedto be paid

• Setting up an information website in the Departmentof Health

• Issuing advice to hospitals and general practitionersregarding returnees from damaged areas

• Establishing a ‘meet and greet’ service for returneeswith the Office of Mental HealthA later task was to welcome our teams home. Each

member was met personally by the Director of MedicalServices at their hospital and given a letter of welcome,information on Methicillin resistant staphylococcusaureus (MRSA) clearances and advice that they couldhave a period of time off work to spend with theirfamilies before returning to normal duties. There wasadditional advice on how to access mental health assis-tance and a consultant psychiatrist volunteered his timefor this.

The final task, of course, was debriefing. The majorrecommendation to the Department of Health in WAwas for the formal development of Disaster MedicalAssistance Teams (DMAT).

It was a hectic 2 weeks. Given world events, it is quitepossible that WA will be asked again to provide assis-tance overseas so we believe our initiatives will be wellplaced.

The first team to Banda Aceh

Norman Gray

After the Boxing Day tsunami the Australian Govern-ment received a number of requests for help fromdifferent countries. It agreed to offer aid, includingurgent medical support. AusAID was asked to orga-nize the response, who in turn asked EMA. EMAinvolved the State Governments and Departments ofHealth. Liaison was made with the RAAF for helpwith transport and intelligence. Intelligence camelargely in the form of ‘Griggsy’ (Dr Bill Griggs), aRAAF reservist and intensivist in Adelaide and a big,larger-than-life character.

Emergency Management Australia and the NewSouth Wales (NSW) Department of Health involved theAmbulance Service, Fire Service, Counter Disaster Unitand Careflight Australia in its preparation. These orga-nizations contributed personnel, logistical support andequipment. For example, Careflight provided a 17-tonnecache of water, food, medical and surgical supplies. Theprocurement was coordinated by the Deputy ChiefHealth Officer for NSW, David Cooper FACEM, whohad four teams of 14 personnel each organized within17 h of the initial request. (He later received a meritori-ous award from the NSW Government.)

Two teams, Alpha and Bravo, were combined asCASTA and sent to Banda Aceh. Charlie team was sentto the Maldives. Echo team was put on stand-by. TheCASTA team had 28 members in all, including teamleader David Flynn and deputy Paul Schumak. Thehierarchy was based on agreement to go by their respec-tive ADF reservist seniority. The team was made up oftwo EP, two general surgeons, two orthopaedic sur-geons, four anaesthetists, two public health specialists,one infectious diseases physician, seven nurses (ED/theatre), two firemen and two paramedics. The mem-bers were derived primarily from NSW and WA. Theteams to follow were to be state-based.

All, like myself, had very little notice. I was called atwork during my day shift and flew to Sydney thatnight. Teams assembled at Richmond Air Base. CASTAwas dispatched via Darwin and Jakarta by the RAAF.The crew from 33 Squadron landed us directly at Banda



89

Aceh, an operational decision based on their assessmentand against normal procedure. This decision was ini-tially censured but was later praised as it turned out tobe correct, saving time and lives.

The airport was a scene of aid trying to get in andrefugees trying to get out. At later times the airport wasclosed by an aircraft collision with a cow and by thevisits of Kofi Annan and Colin Powell. The latter visitinvolved the mythical ‘Griggsy’, who when asked at aphoto opportunity with injured and sick patients whathe was doing, replied in Australian ‘Waiting for you toleave again so we can evacuate these people’.

Arrival was into an area of potential conflict withmuch infrustructure destroyed and perhaps half thepopulation already killed. Only 17 of 350 health work-ers remained accounted for. Two standing health struc-tures remained useable: the Military Hospital (namedso because it had been a military hospital in Dutchtimes) and Fakinah, a private clinic/hospital. We basedourselves in the latter and sent one of two surgicalteams to the former each day. Fakinah was full withthe sick and injured. The overwhelming impressionwas the stench that came from the wounds and spu-tum of the patients. We judged our progress by itsdaily diminishing.

Drinking water, sanitation and electricity were thebasis of our logistical challenges. Thanks to our havingwater, food, doxycycline and a mysterious foggingmachine we maintained good health over the 2 weeksin location. Others were not so lucky, one team struckwith gastroenteritis and another aid group decimatedby malaria.

The threat of flagging morale was avoided bygood communication and the willingness of all mem-bers to play any part the team needed. This, Ibelieve, reflected the maturity and experience of thegroup, with average age in the forties. I base this onmy previous deployment experiences where the aver-age age has been in the low twenties and experienceminimal.

We helped the local workers and population with anaverage inpatient load of 60 patients, up to 300 EDpresentations daily and more than 100 operations.There were about six deaths a day, including one fromtetanus. The locals, used to seeing tetanus, usually diag-nosed it before we did.

Most of the work was wound debridement and treat-ment of aspiration pneumonia. Both pus and sputumhad a similar dirty drain-water appearance. Ketamineand flexibility were the keys to providing pain-free pro-cedures. Ketamine was something the locals did not

seem to use but greatly appreciated. The local medicalstaff, initially suspicious (and reasonably so), eventu-ally asked for our assistance with these matters, butwere reluctant to adopt our measures for themselves.There seemed to be a cultural acceptance of pain asso-ciated with treatment.

In a short time there were many events. Many weretearfully tragic, at the most innate level of human grief.There were many wonderful stories too. Despite lan-guage, culture and ethnic differences the disasterexposed the very best of human capacity to cooperateand to sacrifice for the good others.

The second team to Banda Aceh

Andrew Pearce

The team from SA was made up from a number ofhospitals so not to strain any one hospital over theholiday season. The team mission was to provide sur-gical and medical assistance to the people of BandaAceh while being totally self-sufficient with very littlelikelihood of resupply.

‘Where would we stay, where would we be working,what type of injuries would we face and would we beable to help?’ were some of the thoughts racing throughthe team as we embarked on a 48 h trip to get there.Tired after packing and loading 10 tonnes of equipment,we landed at the military airport at dawn with fewanswers.

Hot, sticky and alone, we stood on the tarmac withall our gear trying to work out how we would get toFakinah clinic/hospital. The mass grave on the roadfrom the airport to the city where many thousands ofbodies were buried was a very sobering reminder of thecatastrophic scale of what had occurred. None of us haddealt with anything like this before. Many of us hadbeen away with the military and had been exposed toharsh environments and human suffering, but this wasdifferent.

The hospital was pretty much intact but with norunning water, intermittent electricity, crowded wardsand burning piles of rubbish outside. There was anabnormal quietness and sadness everywhere we went.There was little time to settle in as a Caesarean sectionwas underway and they needed an anaesthetist. Sleepwas broken by the arrival of Indonesian soldiers alleg-edly shot by rebels in the ongoing civil war.

The long hours in hot conditions did not seemto worry any of the team as they were keen to do

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everything they could to help patients and get the hos-pital back up and running. Skin grafting, external fixa-tion, aspiration pneumonia and tetanus were thecommon challenges. Each day the team would go for anearly morning walk and see the locals cleaning up,smiling and happy to see us. The daily after-shocks,tremors and one 6.4 earthquake certainly made usaware of the remoteness of where we were. Who wouldcome for us if we were hurt?

The team worked hard and well together under veryaustere and trying conditions. We did make a differ-ence. The opportunity helped put in perspective whywe do our jobs and how we can help others in need.

Some of the team were asked to return for the secondmajor earthquake off Nias Island. The extent of thetragedy was felt very hard when we lost members fromthe ADF, our friends and colleagues who were againhelping those in need.

Lessons learned

Andrew Pearce

Team selection and structure

The deployment of Australian civilian medical teams aspart of an international disaster response had not hap-pened since the Vietnam War. On Boxing Day 2004there were no databases from which to generate lists ofpotential team members. The response relied on theAHD-MPC and the relationship with the Chief MedicalOfficers in each state, who then liaised with hospitalmanagers. It also relied on a number of individuals withprevious experience who acted as focal points for teamselection. The system used word of mouth to gather thebest available team. Generally it worked well. However,it might not identify all those with the particular skillmix required, or provide alternatives in the event ofunavailability.

When deploying to a non-English-speaking countryteams should have a translator who can provide cul-tural advice. In Banda Aceh we were fortunate to havea local person who could translate, but he was not aformal part of the team and was not paid.

There is a need for specific training for the roles thatmust be taken by team members outside their regularwork. It would be useful to have a basic curriculum forthis. The model could be similar to the DMAT set-upin the USA. A DMAT is a group of medical and supportpersonnel organized to provide emergency medical careduring a disaster or other unusual event. It deploys with

adequate supplies and equipment to support itself for72 h while providing care at a fixed or temporary site.It is a rapid-response element to supplement local ser-vices until other resources can be mobilized or the situ-ation resolved. There would of course be significant costand work involved in setting up and maintaining suchteams.

Mission statement and roles

The role of the team needs to be clear before the teamis deployed to safeguard against mission creep and self-tasking outside the intended area of activity. It ishuman nature to try to take on more when in a disastersituation. A clear statement of tasks helps to maintainthe focus of the team.

Team leadership

For civilians, the hierarchy within each group needs tobe decided at the time the team is formed. The teamleader needs managerial and people skills and is notgenerally used in a clinical role. This enables the groupto function on both organizational and clinical levelswithout distractions from the main focus. The teamleader reports to the tasking agency, in our case theChief Medical Officer for the State, who then reports tothe AHD-MPC.

The team needs a representative from the taskingagency to help plan the logistics. Arriving in a foreigncountry at dawn in the rain with 10 tonnes of equipmentsome 40 min from your destination without transport isa challenging experience for a team put together onlyseveral days previously.

Conditions of service

The term ‘volunteer’ is used to define a person givingof their time and service without compensation. Thiswas the view held by many people about those involvedin the relief efforts post tsunami. However, the healthworkers were asked as employees, generally from aparticular hospital, if they wanted to go. (There werealso a number of private practitioners involved.) Eachof the states and hospitals determined independentlythe conditions of service for the team members andmost of this was performed on their return. It would beuseful to establish national conditions of service forrespondents to disasters.

Team equipment

There is a need for standardization of equipment. TheUrban Search and Rescue model enables standardizedequipment to be available within each state, to be



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maintained and used by the personnel most likely todeploy with it. Because disasters vary the cache caninclude a basic module that is generic, with add-onspecialty kits, for example for surgery and for chemical,biological and radiation situations.

Work has been performed on the types and quantitiesof drugs and equipment needed to sustain groups aftera disaster. For example in 1998 the Australian MedicalDisaster Coordination Group produced a document enti-tled ‘Pharmaceutical and medical equipment list fordisasters: List of drugs and supplies for 500 persons for3 days’. A list could be standardized and distributedthroughout Australia, to avoid recreating lists andrisking leaving off important items or taking unneces-sary loads.

Standardization is also important for personal sup-plies. Team Echo identified the need for a personalsurvival day-pack, should another earthquake or tsu-nami precipitate the need to evacuate in a hurry. Apersonal survival kit has a number of generic suppliesthat can be prepacked and stored. This allows membersto concentrate on personal gear and on preparing them-selves in the short time available before departure.

Team clothing requires some uniformity. Those whowent to Banda Aceh wore a wide range of attire, someverging on ‘para-military’ and not suitable for the hothumid climate. The rapid deployment of the teams didnot allow for any coordination. Identification of an Aus-tralian humanitarian team needs to be easy. A uniformalso aids the transition from one team to the next, andcan cater for cultural sensitivities. Guidelines for design,fabric and protective qualities could be developed andcould include documentation that identifies the memberas part of a particular team, as recommended by theRed Cross.

Debriefing and follow up

Health-care professionals are not immune to thestresses of deployment to a disaster situation. What wesee and do in some way affects us all and we need toaccept the need to debrief. This can be performed infor-mally, as a group sharing a drink, and formally withthe tasking agency. An immediate debrief is importantfor venting issues before returning to families and part-ners and the daily routine back home. The availabilityof follow up at a later stage is also important.

Role of emergency physicians

All of the teams included an EP. It could be argued thatthe initial resuscitation and stabilization phase hadpassed before the teams arrived and that there were few

evacuations of Australians required, so there was littleneed for EP. However, the participation of the EP as ageneralist involved with resuscitation of sick andinjured, ultrasound for focused assessment with sonog-raphy for trauma (FAST), team health, logistics, com-munications and management of supplies helped thebalance of the team and contributed flexibility. EPenhance the versatility of a team. They are also part ofthe extraction plan in the event of illness or injury inthe team.

The way forward

The ACEM could play a facilitating role for team coor-dination. A website that includes roles, experienceneeded and how to prepare through courses and prac-tical exercises, with links to disaster agencies includingEMA and the AHD-MPC, would be a good startingpoint. A website could include reports from previousmissions and the lessons learnt.

Additional preparedness could include a nationaldatabase accessible through State Departments ofHealth, a planned succession for leadership roles, and adeliberate rotation of personnel to spread corporateexperience and to maintain longevity. The ADF alreadyhas a number of these issues incorporated into dailypractice. Although the military and civilian systems arevery different, there is scope for each to learn from theother’s experiences.

Conclusion

The Boxing Day tsunami presented Australia with adisaster of unprecedented magnitude affecting ourneighbours for which we were unprepared. The ‘can do’Australian attitude certainly assisted the organizationof a number of highly skilled teams in a short period oftime, even over a holiday period. EP, familiar with react-ing rapidly, made substantial contributions to theresponse. We need now to go forward with new knowl-edge and experience to improve our preparedness forthe disaster challenges that we will undoubtedly face inthe future.

Useful websites

1. Australian Health Disaster Management PolicyCommittee (AHD-MPC) http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-disaster-admg.htm

http://www.health.gov.au/

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2. Disaster Medical Assistance Teams (DMAT)http://teams.fema.gov/dmat/about/ndms.html#dmat

3. Emergency Management Australia (EMA)http://www.ema.gov.au/

Author contributions

Paul Mark, Norman Gray and Andrew Pearce con-tributed their personal accounts. Andrew Pearcecontributed the lessons learned. Chris Curry, Chair

of the International Emergency Medicine SpecialInterest Group of ACEM, organized and edited thepaper.

Competing interests

None declared.

Accepted 12 October 2005

http://teams.fema.gov/dmat/about/ndms.html#

http://www.ema.gov.au/

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