Rescue

Orthopaedic surgery after the Aitape tsunami

"No gat mama, no gat papa, no gat pikinini -- olgera i lus pinis long solwara"
Got no mother, got no father, got no children -- all lost forever in the salt water

Annette C Holian and Prue P Keith

MJA 1998; 169: 606-609
 

As the magnitude of the disaster became apparent, there was a flurry of telephone calls between team members. The only thing we could not do was to do nothing. We knew the local hospitals' resources would be quickly overwhelmed, and that, at best, only limited orthopaedic care could be offered. The rapid announcement that an Australian Defence Force (ADF) medical team was to be dispatched was heartening news. We needed to ensure that orthopaedic expertise arrived too.

We contacted the ADF on Sunday 19 July to offer the services of our surgical team (Box 1). They readily agreed and our core team of orthopaedic surgeon, registrar and theatre nurse left as part of the ADF's deployed Joint Task Force, but took almost three days to get to Vanimo (via Sydney, Brisbane, Townsville and Port Moresby). Some days later the remainder of the team made the same journey in 12 hours.

Arriving in the early afternoon of Wednesday 22 July we met with the ADF surgical team and were most impressed! There were over 250 patients in the ADF base. Surgery was constantly being performed and a sense of intense urgency prevailed.

At Vanimo Hospital the situation was quite different. Patients with every imaginable limb injury had been arriving for five days. The two local doctors were coping with over 200 patients and there was an acute shortage of space, beds, linen and nursing staff. Dr Les Roberts-Thompson had spent the first few days in the disaster area giving first aid and sending the injured to the hospital, where Dr John Novette and the health extension officers (who have three years' medical training and assist in the emergency department) provided what further medical care they could.

Only the most severely injured patients had beds in the wards; others slept on the verandahs or on the grass outside under a tarpaulin (Figure 1).

Some single beds accommodated two patients. Sheets, not normally provided by the hospital, were in short supply, with people sleeping directly on the vinyl-covered mattresses. There were very few pillows, and bags of belongings, which on previous visits we had used to elevate limbs, were notably absent. At times only one nurse was responsible for up to 50 patients. Beds were crammed in so closely that there was barely room to step between them (Figure 2).

Each patient had at least one other person sleeping nearby to help care for them.

The Vanimo Hospital's main operating theatre was so small that a trolley could not fit into the room unless the operating table was moved. It opened directly off a covered walkway and had no holding bay or recovery area. A kitchen sink in one corner doubled as a scrub sink and clean-up area. The orthopaedic equipment available was laid out for use: an amputation saw and a T-handled chuck. Fortunately, we had brought with us a general orthopaedic surgical instrument tray. Lois van Heuzen, our theatre nurse, ran between the theatre and the labour ward (where Elizabeth Lewis, one of the surgeons, was attending to wounds), and managed to ensure that our equipment was washed, dried and resterilised ready for each patient. Frequently, this involved only soaking in spirit. It was a challenging environment for orthopaedic surgery.

Many hours were spent examining patients and establishing treatment plan priorities. There were numerous patients with dirty lacerations, penetrating joint injuries, and closed and open fractures who had spent days in salt water or mangrove swamps until help arrived. In addition to their orthopaedic problems, almost all had soft-tissue injuries and most had aspirated salt water. Not surprisingly, some had concurrent malaria.

Record keeping and accurate patient identification were difficult. Before our arrival patients were identified by bed numbers. There were no identification bands and the medical records and radiographs were stored on patients' beds. Unfortunately, some beds had two numbers and other beds had two patients! We identified our patients creatively using key tags, baggage labels and, later, arm bands.

Given the limited orthopaedic tools available, Thursday 23 July was designated as Steinman pin day; we inserted some eight pins and aspirated six knee effusions. The pins were extremely sharp and double-ended. The chuck would not lock reliably on the pins, even with encouragement from the local plumber's pliers. After we had both received penetrating injuries to the palm, we resorted to an unorthodox technique. Holding the sterile pin in one sterile hand, the other, unsterile hand put the plumber's unsterilisable hammer to good use, driving the pin home. We then covered the sharp pin ends with any available tubing, including the rubber tubing from spearfishing slings.

Hard work by a team of Port Moresby theatre nurses, cleaning and hanging curtains to create a recovery area, allowed us to move to the larger outpatients operating theatre, and over the next few days we concentrated on drainage of pus, debridement and stump revision. Surgical priority was based largely on the intensity of odour. Necrotising fasciitis was rampant (Figure 3).

Extensive debridement of fascial sheaths was often required, and wounds were packed open and reviewed regularly to ensure that we kept ahead of infection. It became obvious that several people with swollen limbs and grazes actually had wringer injuries, with degloving, fat necrosis and devitalised muscle. We were still finding foreign bodies in soft tissue a week after our arrival, but as far we are aware no further infections necessitating amputation occurred.

Chris Blackburn, the team's physiotherapist, and John Kinealy, the cast technician, spent every day in the wards. They set up traction on patients as we returned them with their pins or new skin traction. This was difficult, as there were very few traction beds, no proper weights, no knee slings and the adults were too long for the beds. Brother Martin, also of the Passionist order, was engaged to construct some wooden frames to elevate limbs. These were lined with rice bags held in place by thumbtacks. The rice bags were also used to construct pelvic traction for a girl with diastasis of the pelvis. Fruit juice bottles filled with sand were used as weights (Figure 4).

As beds with overhead beams were scarce, beds were positioned under the partly demolished partitions when required and traction suspended from the roof.

Chest physiotherapy was vital for most of the patients. Chris spent hours making "bubble-pep" equipment from mineral water bottles, oxygen tubing and dish-washing liquid, then encouraging the children to blow, breathe, blow.

As the days wore on, the condition of the patients on the grass became of increasing concern. Several were able to walk, but with significant limps and a swollen knee. When examined their expression of pain was so minimal that our initial clinical diagnosis was of a complete rupture of the medial ligament of the knee. A radiograph performed before casting revealed the true diagnosis -- a depressed lateral tibial plateau fracture. Patients with these fractures and with medial ligament injuries to the knee were immobilised in plaster cylinders topped with fibreglass to counteract the negative effect of humidity on the plaster.

Medically, we performed complementary functions, each taking responsibility for patients on our own site, but readily transferring patients between sites to facilitate their care. Vanimo Hospital took patients who needed immediate specialist orthopaedic care or were stable enough to rest in bed with the available level of nursing care. To expedite their surgery, we temporarily transferred to the ADF some patients who needed dressing changes and possible further wound debridement. The ADF also helped to conduct a large scale transfer of patients from Vanimo to Wewak.

Wewak Hospital is the surgical centre for the Sandaun and East Sepik Provinces of PNG. It offered many attractions for the management of our patients, none more so than its remarkable resident general surgeon, Sister Martin Joseph, a British vascular surgeon trained at St Bartholomew's Hospital, London, and belonging to the Passionist order.

Sister Joseph informed us that their operating theatres were open and staff ready for surgery. We knew from previous visits that the theatres, equipment, sterilising capabilities and nursing staff cover were all superior to those at Vanimo. As the surgeon responsible for the region, Sister Joseph would also be the most capable hands in which to leave the more complex cases for ongoing medical care.

Careful thought was given as to which patients to take. The need for further surgery, including internal fixation, as well as the need for continuing close observation, physiotherapy, and proximity to family and friends were all taken into consideration.

Patients were transferred to Wewak on two C-130 Hercules aircraft flights: the first occurred on Sunday 26 July and the second, larger group followed on Tuesday 28 July. These were both impeccably organised events and constituted, we were informed later, the largest transfers of injured patients performed by the ADF since the Vietnam War.

Preparation for transfer included femoral nerve blocks, application of Donway splints, tying off traction, and splitting some encircling casts. Patients were ferried to the airfield by open truck, assembled and loaded on to the aircraft. Personal luggage, walking wounded, families, stretcher patients and finally our mission-made frames and other supplies were all neatly stacked in the aircraft. Stretchers were suspended three deep on taut seatbelt webbing that hung vertically from the aircraft's roof. We could only begin to imagine the anxiety that the children on board must have been experiencing.

We reviewed our surgical capabilities. Our orthopaedic tools now included a Mathys rechargeable drill/wire driver/oscillating saw, boxes of Howmedica GK intramedullary nails (size 12-16) without reamers, a K-rod set with an almost complete set of T-handled reamers up to size 12, an assortment of external fixation equipment, as well as various loose screws and recycled plates without the appropriate drills, taps or depth gauge; nothing matched and no "set" was complete.

Desperate attempts over the next few days to get better equipment from various sources were largely unsuccessful. Equipment was stalled in Customs, held up by transport companies, arrived incomplete or just disappeared.

We planned a surgery list each day by trying to match up the fixation devices available with patient requirements. Tibial external fixateurs were constructed mostly from old Hoffman blocks, but as one type of connector was missing constructs were not always optimal. One frame was put on an open fracture of the ulna for which there were two blocks but only three pins. The fourth pin was created by putting some split intravenous tubing around a long cortical screw. The bar was a Steinman pin that fitted the block beautifully.

One child had a fractured neck of femur, which we decided needed to be internally fixed to reduce the risk of non-union. In the absence of any conventional implant or image intensifier, we did an open reduction and secured the fracture with a tibial plateau T-plate with two cancellous screws along the femoral neck. The postoperative radiograph looked promising.

In the third week we managed to obtain some basic and small-fragment instruments that allowed us to spend a satisfying, albeit difficult, day fixing the adult forearm fractures.

On Thursday 6 August, nearly three weeks after injury, the remaining adults with complex, segmental and comminuted femoral fractures were treated. Open reduction was not easy but was ultimately achieved. Only two patients with fractures that we had expected to treat with internal fixation remained. One, an adult with a forearm fracture, had nearly succumbed to pneumonia and was not fit enough for anaesthesia, and the other had refused surgery.

However, the orthopaedic disaster is not over yet. There will be people with non-union, delayed union, malunion, infections, physeal arrest and other unforeseen complications. Further operations will be necessary. Ideally, these should occur close to the patient's home and family and with the optimal equipment available to the surgical team. We will be back.

Reprints: Miss A C Holian, Monash Medical Centre, Locked Bag 29, Clayton, VIC 3168.
Email: pruekATozemail.com.au

©MJA 1998
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