Rescue Operation Shaddock -- the Australian Defence Force response to the tsunami disaster in Papua New Guinea Operation Shaddock was the name given to the deployment of a major
field medical unit of 58 Australian Defence Force medical and other
personnel to Vanimo, in northwestern Papua New Guinea. Hundreds of
victims of the tsunami disaster were treated and more than 200
surgical procedures performed in a 10-day mission.
Paul R P Taylor, David L Emonson and James E Schlimmer
MJA 1998; 169: 602-606
Introduction -
A command perspective -
A clinical perspective -
Conclusions -
Authors' details
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| Introduction | ||||
When the extent of the devastation caused by the Aitape tsunami (Box 1)
was realised, over 12 hours after the wave hit, a request from the
Government of Papua New Guinea (PNG) for air transport support and a field hospital was sent to the Australian Government aid agency
AusAid. The request was passed to Emergency Management Australia(the link organisation between military and civilian agencies), which in turn asked the Australian Defence Force (ADF) to respond. By 1900 on Saturday 18 July, the requirements were more clearly defined as:
Personnel from the 1st Parachute Surgical Team, the 1st Field Hospital and an Aeromedical Evacuation (AME) team from No. 3 RAAF Hospital (all Sydney units, based at Holsworthy and Richmond) worked through the night of 18 September to prepare essential equipment. Early on the evening of Sunday 19 July two RAAF C-130 transport aircraft carrying the health facility left Richmond RAAF base and landed at dawn the next day at Vanimo, a town some 70 km to the west of the disaster area. By nightfall the initial team of 25 ADF health personnel (six doctors, six nurses, two operating theatre technicians, 10 medical assistants and a preventive medicine officer), supported by logistics, movements and communications staff, had erected a field health facility around an abandoned PNG military barracks about 1 km from Vanimo hospital. The threat of further seismological events was very real and an evacuation plan was put in place in the event of a subsequent tsunami. The team worked around the clock for the next four days, stopping only briefly to grab a snack from field ration packs.
The ADF team at Vanimo was later reinforced by an orthopaedic surgical team (three surgeons, one physiotherapist, one operating theatre nurse and a cast technician) from Monash Medical Centre in Melbourne (see Holian & Keith), an additional ADF orthopaedic surgical team (surgeon and anaesthetist from Sydney), a health team from the New Zealand Defence Force (NZDF) and one from the US military (one surgeon, two preventive medicine officers). An ADF health team consisting of a medical officer, a nursing officer, a health logistician and two health administration officers, who were in Port Moresby to assist in the review of the PNG Defence Force Health Services, were also made available to support the mission. In total, 251 patients were treated at the ADF health facility during Operation Shaddock and 209 surgical procedures were completed. Hundreds more patients were seen and treated by the teams in the disaster area and the care centres. Only two deaths occurred in the facility, both non-surgical cases involving aspiration pneumonitis from near-drowning. While the surgeons operated, primary health care and public health teams worked with engineers and aircrew to prevent the outbreak of disease. ADF personnel were involved in ensuring that drinking water was potable, waste (including sewage) was disposed of, and the dead were buried. RAAF aircrew worked to transport food, water, and counterdisaster equipment, and to evacuate the victims of the disaster. In all, nearly 200 ADF personnel contributed to Operation Shaddock.
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A command perspective | ||||
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The immediate challenge to the Parachute Surgical Team and other
units was how to plan for a disaster in which, potentially, the scale of
destruction and the numbers of injured were enormous, but for which
exact details were unknown. We also had to tailor our units, designed
to treat war wounds of fit young men, to care for the young and the old
with all types of injuries and concurrent medical illnesses.
All that Saturday night (18 July) we worked to deploy in 14 hours an organisation which notionally requires seven days' notice. Personnel were recalled to duty and worked around the clock to pack equipment and procure items from stores. The next morning was spent reconciling orders and deliveries, further packing, and in briefings and administration. By mid-morning on Sunday 19 July the trucks and buses arrived to take us to RAAF Richmond. Even before we left we were weary. The first flight left at last light, arriving in Port Moresby at 0300 Monday morning (20 July). After quickly refuelling and changing crew, we took off for Vanimo, arriving just as dawn broke. It was now 52 hours after the first tsunami had struck. We arrived amid preparations for the third day of the evacuation of people from the disaster area. Every available light aircraft and helicopter was being prepared for non-stop operations in the daylight hours in an attempt to complete the evacuation. Brother James Coucher, the missionary who had been coordinating the relief effort so far, was at the airport, exhausted but obviously relieved and happy to see us. In a desperate bid to maximise the evacuation airlift back to Vanimo, casualties had been brought in piled on top of one another, with injured limbs lying at odd angles. Placing the injured in splints and on stretchers would have greatly reduced the numbers able to be evacuated. Pilots described having to perform triage themselves in making decisions about who to leave behind. Teams consisting of a doctor, an interpreter and a medical assistant were immediately sent into the disaster area in order to collect information on the situation. The evacuees and those still awaiting evacuation appeared bewildered. The scale of the disaster was simply incomprehensible to them. Entire communities had been washed away in a moment. Everyone had lost at least one relative; many had lost all. Many survivors were wandering around the lagoon desperately trying to find a relative, dead or alive. The evacuation was in its last stages. The issues now needing attention were those of displaced people, disposal of the dead, and the definitive treatment of patients already evacuated. Our first action, while setting up the facility, was to visit each of the care centres and the hospital in Vanimo. Vanimo Hospital did not have surgical staff, so several patients required immediate surgery. Nine major surgical procedures were undertaken at Vanimo before the field hospital was set up. Other patients requiring surgery were found in the care centres. The response by the local population in Vanimo was overwhelming. Within minutes of our arrival, a fleet of vehicles was at our disposal, and pledges given for all the assistance we could ask for. Local church communities guaranteed that all of the patients would be fed and looked after, and that orphans would have someone by their bed. Our field hospital consisted of a triage/resuscitation area, an operating theatre with equipment to run two operating tables, a self-contained ward facility with 20 beds, supported by x-ray, pathology (we could perform most routine tests and cross-match blood), and a preventive medicine laboratory. Initially, we ran two operating tables and a third for minor wound debridement. Our staff comprised a consultant surgeon, an orthopaedic registrar, a consultant anaesthetist and three general duties medical officers.
The pace was similarly hectic on the second and third days; however, by the end of the fourth day, as most of the primary surgery has been completed, the pace began to slow. Then a phone call from Aitape reported that a patient had developed gas gangrene. A light aircraft and a pilot were found within an hour of last light and dispatched to retrieve this patient as well as some with less serious conditions. The aircraft returned with 13 patients, all requiring surgery that night! During the second week tactical aeromedical evacuation of patients was undertaken to spread the surgical workload between the hospitals at Vanimo, Wewak and Aitape. This also enabled us, working with the Monash Orthopaedic Surgical Team, to move nearly 40 patients (and relatives) to Wewak Hospital, where the operating and recovery facilities were more suited to patients needing orthopaedic surgery. After the fifth day the majority of surgery undertaken involved delayed primary closure of wounds, with or without skin grafting. The wider problems were now largely those of coordination and appropriate management of the care centres for displaced people and the attendant public health implications. Significant effort was needed to channel the international donations of staff and supplies to areas of need. Coordination of resources is the key to any disaster relief situation. In time, the organisation and response became increasingly efficient. The care centres were well set up inland, and various teams, both military and civilian, were providing basic medical care, well organised shelter and food. By 10 days after arrival, the workload was declining (Box 2). Each patient's wounds had been debrided, and many wounds were now closed or grafts had been performed. Although surgical procedures were performed right up to the last day of the deployment, we concentrated our efforts in the last few days on discharging patients from the ADF facility and arranging their ongoing care within local health facilities. When our remaining postoperative patients had been transferred we stopped operating, with only three out of 209 surgical patients still requiring wound closure.
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A clinical perspective | ||||
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As we arrived in Vanimo 52 hours after the tsunami, we had missed the
first two peaks in deaths from trauma (Box 3), but had arrived in time to
prevent the third peak, which occurs several days or weeks after
injury. Indeed, the ADF contingent treated no patients with
intracranial, intrathoracic, abdominal or spinal injuries as these
patients had already succumbed before our deployment. Furthermore,
few infants and elderly people had survived.
Every patient treated on the first day had some degree of aspiration pneumonitis from near-drowning. Two patients were admitted in respiratory failure and treated with antibiotics, nebulisers and oxygen, but had little chance of survival. Many also had underlying respiratory disease; tuberculosis is endemic in the local communities. Anaemia was also common, usually owing to malaria or intestinal parasite infestation. All these problems complicated the patients' anaesthetic and surgical management. There were many large flap scalp lacerations caused by floating debris, and many fractures and dislocations, both open and closed. At least a quarter of all patients were children, many with simple soft-tissue injuries and lacerations.
Many patients required immediate surgery, but those triaged into the delayed-treatment group were rapidly deteriorating. All wounds were grossly septic and contaminated with foreign material such as sand, coral and vegetation and, as such, were at least limb if not life threatening. Many victims had been impaled upon the mangroves behind the Sissano lagoon by the force of the waves. The complete destruction of village aid posts and their workers resulted in virtually no medical attention being available to casualties initially. Dehydration compounded blood loss and worsening cardiovascular shock. Patients with large bone fractures were often transported unsplinted, and some developed presumed fat embolism syndrome, further worsening their preoperative condition.
Surgery All patients brought to the ADF facility were initially rapidly triaged, with assessment and resuscitation proceeding simultaneously. All casualties were treated according to Australian Defence Force casualty treatment regimens -- a system of simple, reliable, reproducible treatment protocols based on accepted practice. Surgical procedures were based on principles espoused by the Red Cross (Box 4), which has by far the most extensive current experience of dealing with large numbers of casualties in situations with limited resources.
All wounds were extensively debrided and devitalised tissue removed. An aggressive approach was often required, and 14 amputations were performed. Fractures were aligned and immobilised with plaster slabs and improvised splints. Open fractures were debrided and thoroughly lavaged with sterile saline and immobilised with combinations of plaster and skeletal traction. Femoral fractures were managed initially with skeletal traction using Steinman pins and the patients were then flown to Wewak for definitive treatment by the Monash orthopaedic surgical team. Surgery was performed in two stages -- initial wound surgery, and then delayed primary closure. All surgical wounds were left open, using ample absorbent gauze dressings. Chloramphenicol and metronidazole, used in local practice and hence readily available, were used for antibiotic cover. Delayed primary closure was carried out four to five days later, as were the first split skin grafts. All split skin grafts were successful, at least until the time of our departure! Six wounds required further debridement. The parameters of odour, temperature and pulse rate were effective in identifying patients in whom initial debridement had been inadequate.
Anaesthesia With such great demands on our meagre resources, there was a need to adopt a "standardised" approach to anaesthesia while still tailoring techniques to individual patients. As a result, recovery staff and medical assistants with little or no experience knew what to expect and how to manage patients postoperatively. Airway management, monitoring, induction and maintenance of anaesthesia often had to be performed before complete volume expansion had been achieved. Despite good interpreters, a complete medical history was frequently lacking and we thus had to be ever- vigilant for occult injuries and problems. We would often be overseeing three or sometimes four or five patients under general anaesthesia, with assistance from the ADF general medical officers. Anaesthesia was kept simple and safe and, where possible, the selection of anaesthetic agents was individualised. No premedications were used. For induction, ketamine was preferred, although thiopentone and propofol (Diprivan; ICI) were also used. Ketamine, which does not induce hypotension on induction and stimulates ventilation, was most suitable in these circumstances. In some cases, rapid-sequence induction and intubation using suxamethonium was used. Laryngeal mask airways were extensively used, as spontaneous breathing was the order of the day. This was safe, made monitoring simpler, used resources (one ventilator) more effectively and allowed a greater margin of error -- we were all exhausted. We used oxygen concentrators for oxygen supply. These are solid little machines producing 3-4 L/min of 90%-95% oxygen. We did not take nitrous oxide, which was considered dangerous cargo by the RAAF. Maintenance of anaesthesia was achieved with either ketamine, halothane or isoflurane. Narcotics were given intraoperatively; fentanyl, preferred because of its short half-life and high potency, was given intravenously. A standard combination of crystalloid and colloid (Hartmann's solution and Haemaccel) was used for intravenous volume replacement. Transfusions (a maximum of two units per patient, as supply was limited) were given when indicated; blood was obtained initially from Sydney and later from Port Moresby. Non-invasive methods of intraoperative monitoring were used. At times monitoring equipment was in short supply. Blood pressure, electrocardiograms, pulse oximetry and capnography provided basic information and proved reliable. Very little local or regional anaesthesia was used. Brachial plexus blocks were successful; however, spinal or epidural blocks were generally contraindicated because of coexisting sepsis. Postoperative requirements for opiates were minimal. The patients were uncomplaining; in some instances they had to be forced to accept pain relief. The atmosphere on the wards was sombre. The enormity of the disaster was simply too great to comprehend in those first few days. All of our patients looked shell-shocked, simply lying still, and taking little food.
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Conclusions | ||||
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In all, 124 primary surgical procedures and 85 secondary procedures
were performed at the ADF health facility in Vanimo in the space of 10
days. In addition, about 25 other patients were operated on by ADF
personnel at both Vanimo and Wewak hospitals.
The success of our mission, in both humanitarian and international terms, lay in the ADF team approach -- fast, efficient and effective management of the casualties, and utilisation of all available personnel and resources for the best possible patient care. Medical officers, nursing officers and medical assistants, both regulars and reservists, all worked tirelessly to achieve this common goal. When we completed our mission each of the hospitals and care centres in the area had the staff, experience, stores and pharmaceuticals needed to continue its work. Displaced persons camps were well established, with shelter, clean water, food, health support and appropriate preventive health measures in place. Vaccination programs were planned, and resources and staffing needs identified. We were satisfied that we were leaving with all of the infrastructure in place to cope with the needs of the people, now and for the foreseeable future. Many of the soldiers deployed knew well the stories of how, during the second world war, the PNG people, who became known as the "fuzzy wuzzy angels", had helped wounded Australian soldiers back to aid posts. We considered our mission as simply "returning an old favour". A very moving farewell "sing sing" was testimony to the difference that our efforts had made and of the special relationship that exists between Australia and Papua New Guinea.
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Authors' details | ||||
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Holsworthy MILPO, Sydney, NSW.
Paul R P Taylor, MB ChB, FRCS(Edin), Major, Officer Commanding, 1st Parachute Surgical Team, Coral Lines. James E Schlimmer, MB BCh, MMed(Anaes), Major; Medical Officer and Anaesthetist, 1st Field Hospital, Manunda Lines. Defence Health Service Branch, Canberra, ACT.
Reprints will not be available from the authors. ©MJA 1998 | ||||
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