Portal de Periódicos da CAPES

A Calling Takes Young EP to Indonesia in Tsunamiʼs Wake

2005; Lippincott Williams & Wilkins; Volume: 27; Issue: 9 Linguagem: Inglês

10.1097/00132981-200509000-00044

1552-3624

David O. Ross,

Disaster Response and Management

Guys, they need more help in Indonesia,” Brian Crawford, MD, announced to the partners of his emergency medicine group in late January. It was that simple statement that allowed Dr. Crawford, working with his group, Front Range Emergency Specialists (FRES) in Colorado Springs, to get his ED shifts covered for January, February, and March. Dr. Crawford's colleagues at FRES understand his avocation with international medical relief work. They have supported his mission by providing coverage for his work schedule in the emergency department when his service has been urgently requested by worldwide organizations. In 2001, he served in Guatemala, assisting with earthquake disaster training. Since his employment at FRES in 2001, Dr. Crawford made his second visit to Haiti in 2004, participating in a post-conflict disaster assessment of a hospital after the departure of President Aristide.Figure: Dr. Brian Crawford, left, with colleagues on board the USNS Mercy.Dr. Crawford has been interested in international medical service for many years. As a premedical student at Creighton University in Omaha, NE, he completed the requirements for his political science major with an emphasis in international relations in addition to the required science prerequisites. After completing medical school at Creighton, he decided that specializing in emergency medicine would best equip him to manage the care of patients around the world victimized by major disasters. Dr. Crawford pursued his residency in emergency medicine at Michigan State University. As a resident, he made his first trip to Haiti, and operated a rural clinic in the Dominican Republic. He also was involved in the assessment of health care at a Haitian refugee camp. “Although I have never seen devastation like we saw in Aceh, what I will remember are the hugs.” Dr. Brian Crawford Unparalleled Devastation Finally, cementing his interests in international relations and emergency medicine, Dr. Crawford attended a fellowship in international disaster medicine in June 2001. As an international disaster medicine fellow at the University of Massachusetts, Dr. Crawford enrolled in the Boston University School of Public Health, and is currently pursuing a master's degree at the Johns Hopkins University Bloomberg School of Public Health. Dr. Crawford's assignment to Indonesia from late January to early March proved to be the most significant of his young career in international disaster relief. As the whole world knows, the devastation following the tsunami in Indonesia has been unparalleled. On this particular mission, Dr. Crawford's services were requested to support the operation of a hospital ship, the USNS Mercy. The ship is a fully functional tertiary hospital with the capacity for 1,000 beds, if needed. Use of the Mercy was a combined effort of Project HOPE, a private organization committed to worldwide health improvement and education, and the U.S. Navy. Prior to deploying to Indonesia, Dr. Crawford and a mix of civilian and military providers underwent extensive training in the capabilities of the USNS Mercy. Initial orientation occurred for two days in late January on a sister ship, the USNS Comfort, based near Baltimore. “Indonesia is the most populated Muslim country in the world, numbering more than 200 million people,” Dr. Crawford observed. “In fact, overall, it is the fourth most populated nation in the world.” Following completion of the orientation phase, the group traveled for 16 hours to Singapore, and boarded the Mercy for the first time on Jan. 28. On Jan. 31, the Mercy was tugged out of Singapore Harbor and set sail for Indonesia. Finally, they arrived off the sparsely lit coast of Aceh (ah-chay) province in the Sumatra region on the night of Feb. 1. Thousands of Deaths Despite the briefings they received prior to arrival in the area, the scenes that greeted the Mercy's medical staff the following morning were overwhelming. In Aceh province, the hardest hit area of Indonesia, the population had been four million. Following the tsunami, deaths were estimated at more than 124,000. The capital city of Banda Aceh itself had a pre-tsunami population of approximately 600,000. After the tsunami, displaced or homeless survivors numbered more than 400,000. There were 10 hospitals in the area before the disaster. Following the tsunami, five of these hospitals were completely destroyed, and the remaining five were heavily damaged. Large segments of neighborhood homes were leveled, leaving only foundations. “The destruction was greater than it might have been because often building construction fails to meet codes,” according to Dr. Crawford. In some neighborhoods, surviving residents came back to their properties and erected tents where houses had once stood. Heavily forested areas were completely denuded. A freighter ship that had been docked at the port of Banda Aceh on Dec. 26 was driven two kilometers into the heart of the city by the waters of the tsunami. In addition to the initial losses of material and equipment, obtaining more supplies was very difficult. Severe damage to the port of Banda Aceh significantly restricted shipping access to the city and region. Dr. Crawford said eyewitnesses reported that the waters of the tsunami reached higher than 50 meters (150 feet). “Since the tsunami was the result of an earthquake measuring 9.0 on the Richter scale with an epicenter 250 kilometers from Aceh province, a wave of this magnitude was possible,” he added. Indeed, the top of Muslim prayer towers in Banda Aceh exceed 50 meters in height. The fact that some prayer towers clearly demonstrate tsunami damage at that height is further evidence for these reports. The Mercy's health care providers were quartered off shore on the ship, but made frequent trips into the Aceh area. Most of the time, the staff provided assistance to health care providers at the Zainal Abidin (AZ) University Hospital. The work was long and arduous, averaging 14 hours a day.Figure: Water and mud damage at AZ University Hospital in Banda Aceh.Damaged Hospitals AZ University Hospital had been heavily damaged as a result of the tsunami. Feet of mud caked the grounds and floor of the facility. Workers labored constantly to remove the mud and debris during the Mercy's staff tenure in the region. Despite the effects of the water, the hospital was operational although limited in services. As international medical contingents converged on Banda Aceh after the disaster, AZ University Hospital's wards were divided among the multinational providers. Medical personnel had come from Germany, Austria, France, Philippines, Singapore, Yemen, and Portugal, as well as the United States. Dr. Crawford played a key role in the assessment of the many patients presenting to AZ University Hospital, ultimately deciding which of these patients might benefit the most from transfer to the Mercy. Patients considered eligible for the Mercy were flown on U.S. Navy helicopters from AZ to the ship. Once the patients were on board, Dr. Crawford's primary duty was to coordinate and triage all patients utilizing a 35-bed monitored unit. “Typically the immediate surgical/medical needs are greatest in the first 72 hours after a disaster,” Dr. Crawford said. “In that sense, the tsunami was not unique from other major catastrophes; it's just that the scale was beyond comprehension. “Once the 72-hour window has passed, the health needs are different. The vast majority of patients (80%) at this point fall into the minor category with injuries categorized by lacerations, burns, fractures, and contusions. Ten percent of patients have major injuries either from complications of the tsunami or sustained after the disaster. The remaining 10 percent have major medical problems such as aspiration pneumonia, ARDS, myocardial infarctions, sepsis, intracranial abscesses, and the like. “As in most situations, post-disaster vector-borne illness is a significant concern,” Dr. Crawford continued. “This was the case in Indonesia as well. However, the salinity of the sea water lessened cholera as an issue. Polymicrobial infections were common.” Bacteria unusual to most American physicians were recovered from the respiratory tracts of patients with exposure to the waters of the tsunami. “Burkholderia pseudomallei and Nocardia were seen with some frequency,” Dr. Crawford said. Standard antibiotic treatment for aspiration in Indonesia consisted of ampicillin, gentamicin and metronidazole, or ticarcillin and clotrimazole. Secondarily, carbapenems were employed. PICC lines were commonly placed by staff on the Mercy. One increasingly common organism in the United States that unfortunately found its way on board the Mercy was methicillin-resistant Staphylococcus aureus (MRSA). “Like hospitals back home, we had to deal with MRSA in addition to the more exotic bacteria we encountered,” Dr. Crawford said. “All patients in Indonesia are considered high risk for tuberculosis. As a result, staff always wore the N,95 protective mask when aerosolized infective exposure was likely.” Memories of Patients Many patients Dr. Crawford cared for remain fresh in his mind. He recalls a number of individuals with long bone fractures (open and closed) of the upper and lower extremities sustained in the tsunami. Fractures were splinted for weeks with bamboo shoots until definitive treatment was obtained. A 17-year-old girl nearly drowned in the tsunami. She was pulled underwater twice by the tremendously strong current. Her brother was able to pull her out of the path of the rising water, and the two survived. Their mother, who was nearby at the time, did not.Figure: This freighter was moved two kilometers by the waters of the tsunami.About 10 days later, the girl developed a fever and cough. Shortly after, she was noted to have right-sided weakness and dysarthria. After presenting to AZ University Hospital, she was initially evaluated by the Australian medical staff. A presumptive diagnosis of aspiration pneumonia complicated by a probable brain abscess was made. The patient was transferred to the Mercy. A CT scan of the brain was obtained, confirming the diagnostic impression. After prolonged antibiotic therapy, the patient made a nearly complete recovery. An 18-year-old young man was admitted to a local hospital after suffering a post-tsunami moped accident. After laying on a gurney for approximately 12 hours, he became obtunded and aspirated. He developed adult respiratory distress syndrome (ARDS), and was flown to the Mercy. He was intubated and placed on ventilatory support. A head CT scan revealed multiple intracranial contusions resulting in altered mental status and aspiration. After many days in the intensive care unit on the Mercy, the patient recovered. In addition to the medical and surgical problems encountered, Dr. Crawford noted significant psychological effects in many patients as a result of the tsunami. Often the staff on the Mercy would take recovering patients onto the ship's deck for an outing. Not surprisingly, some patients had difficulty viewing even the most tranquil sea after living through the catastrophe of such a water disaster. Intense psychotherapy was available to patients. Dr. Crawford also had some exposure to emergency medical services operations in the Banda Aceh region. He described most of the care as very basic life support or “scoop-and-run.” He participated in training military and civilian EMS providers while in Banda Aceh, with their education primarily involving basic airway maneuvers and spinal injury precautions and packaging. As the United States did in the aftermath of Sept. 11, 2001, Indonesia has had many heroes following the devastation of the tsunami. The medical director of the AZ University Hospital in Banda Aceh lost both his wife and daughter on Dec. 26, but he was nonetheless at the hospital within a few hours helping with the endless crush of patients. As the leader of the facility, this physician continued to care for individual patients while directing the overall strategy for managing all patients.Figure: This drawing of a coffin was done by a child who survived the tsunami.As the Indonesian military and medical personnel became more able to cope with the casualties, the USNS Mercy's time in the region drew to a close. The last day to accept new patients on the hospital ship was March 10. The ship and remaining crew departed the area on March 16. Some patients on the Mercy were flown to hospitals in Jakarta or transferred to a tent hospital in Aceh operated by the International Committee of the Red Cross. Here in Colorado Springs, our emergency medicine group, FRES, is happy to have Dr. Crawford home safely. They know he is ready to serve again when needed. FRES supports his commitment because in a small way it offers the group a means to assist others around the world suffering from incredible misfortune. Indeed, at the time of this writing, the Banda Aceh area has experienced at least two more major earthquakes. Fortunately, no tsunami was associated with these quakes, but there have been at least 1,000 more deaths. Project HOPE again is soliciting health care volunteers. For more information, visit its web site at www.projecthope.org. For an overall assessment of volunteer health care needs in Indonesia, visit www.reliefweb.com. “As an ED doctor, the skills I have learned were so useful,” Dr. Crawford said. “My training was very appropriate in my job of providing prehospital and triage patient assessment. In addition, my background prepared me to do a lot of basic medical care teaching, which I did a lot of in Indonesia. It's always sad to lose a life, but it's even worse when the life is lost due to a lack of basic medical knowledge. “In emergency medicine we learn to quickly determine if a patient is sick or not sick. I used that ability hourly. The best part of being in Indonesia was the incredible gratitude of the many patients and the local medical staff we were able to help. Although I have never seen devastation like we saw in Aceh, what I will remember are the hugs,” Dr. Crawford said.