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Treating the injured and burying the dead
World Report
Treating the injured and burying the dead Doctors bore the brunt of the immediate relief effort across southeast Asia. While thousands of dead bodies piled up outside hospital buildings, surgeons worked tirelessly to treat those with infected wounds. Hannah Brown talks to doctors involved in caring for the tsunamis’ survivors.
Oxford Cartographers, 2005
“It was full of dead and dying people. Not a few, but hundreds”, recalls Seevali Tillakaratna, a surgeon at Karapitiya Teaching Hospital in Galle, Sri Lanka, one of the towns most affected by the devastating tsunamis that ripped through southeast Asia on Dec 26, 2004. From relative safety on a hillock near Galle, Tillakaratna remembers surveying the ruined town below. “The devastation was unbelievable”, he says. “Huge buses were toppled and most of the buildings were mere rubble.” In the hours after the waves came crashing into the shores of a dozen countries bordering the Indian ocean, doctors bore the brunt of the immediate relief work. Tillakaratna and his colleagues, like physicians all over southeast Asia, rushed to their hospitals and embarked on marathon shifts to treat the injured and deal with the dead. The huge numbers of dead bodies marked out this disaster beyond all others. Just 1 day after the tsunamis,
204
Karapitiya hospital was full of dead. Nearly 800 bodies were piled on the floor in the outpatient department building and the recreation hall of the psychiatry unit, explains urological surgeon Anuruddha Abeygunasekera, a colleague of Tillakaratna’s. “There were not enough refrigerators or even beds available”, he adds. Raja Sabapathy, head of the department of plastic surgery, Ganga Hospital, Coinbatore, India, says dealing with thousands of dead bodies was a situation for which he and his colleagues were least prepared. There were no stretchers to carry bodies or sheets to cover the rotting ones. “All of us gave money and planned for the living people, but nobody thought of the dead”, he laments. Fearful of disease being spread by bodies rotting in the tropical heat, people have been burying corpses in mass graves, or giving them temporary burials in an effort to delay the decaying
process. But relatives’ and survivors’ demands for identification of the dead mean clean-up activities come second to the massive forensic operation. Somboon Thamtakerngkit, of the Department of Forensic Medicine, Siriraj Hospital, Thailand, says 2 weeks on from the disaster, bodies are no longer recognisable. “Differentiation among western and eastern people was not too difficult in the early days, but now it has become hard”, he says. Thamtakerngkit says his department dispatched 52 volunteers to Phang Nga province, one of Thailand’s worst affected areas. The team recorded memorable features of the bodies, took tissue samples, and wrapped identification tags round the wrists of corpses. But the rapid decay meant the workers soon had to move on to taking samples of muscle and cartilage to ensure DNA tests could identify the dead, even after the body had decomposed. Dentists have become particularly valuable, especially in Thailand where relations of the foreign tourists involved are putting pressure on the country for proper identification of the dead. Kittipong Dhanuthai, a Thai dentist from Chulalongkorn University, who has been involved in the identification efforts, explains that all of the eight schools of dentistry in Thailand have sent teams to the coast to help x-ray the teeth of dead bodies, analyse filling material, and remove teeth for analysis. The team had just four mobile x-ray units for the thousands of bodies; although there were no lead aprons to protect the operators from radiation. Several doctors from the region believe the vast numbers of dead and the small numbers of major injuries in survivors are an indication that severely injured people did not survive the 20 min battering by the tsunami waves. www.thelancet.com Vol 365 January 15, 2005
World Report
www.thelancet.com Vol 365 January 15, 2005
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
abated, she says. The current priority is preventing emerging diseases. Much media attention has focused on the emerging threats of infectious disease spread through camps of people made homeless by the tsunamis. But according to AP Dash, a professor of medical entomology for the Indian Medical Research Council, the tsunami has had “no direct impact either on increasing or causing outbreaks of vector-borne disease”. He led a team in Tamil Nadu in southern India that conducted a survey of coastal areas affected by the waves to identify dengue vectors and other emerging diseases. He plans to re-survey the areas in the coming weeks. Aroona Abdulla, part of a relief team from the University of Colombo’s faculty of medicine, says patients with chronic diseases have largely been forgotten in the emergency. Many who regularly take medication lost their supplies in the waves, and were uncatered for in emergency relief packages. WHO is now emphasising that surveillance is the key to preventing major outbreaks in camps housing those left homeless. And while systems are up and running in Sri Lanka and Thailand, Indonesia is yet to establish a reliable reporting system. The damage to health facilities in Indonesia far outstrips that in other countries. A progress report compiled last week by NGOs working in Indonesia estimated that at least 77 health centres and eight hospitals were damaged. These numbers are expected to rise. The medical laboratory in Banda Aceh has been washed away; so, too, has the provincial health office. 50% of the health workers were dead or missing. As the need for emergency care recedes, the health needs of the population move away from acute care, according to Abdulla. Public-health support is now a priority along with educating local health workers about the management of tsunami injuries. Abdulla’s team from the University of Colombo has organised relief activities
for coastal areas, including provision of drugs and medical attention. The team is also helping to educate homeless populations on prevention of disease and hygiene, bringing some order to the disorganised initial activities. Even so, the impact of this disaster remains devastating. Many doctors worry that survivors who have lost everything will see no reason to go on. “There have been suicides already”, one doctor comments. “Let’s hope this nightmare is over soon.”
Hannah Brown
Rights were not granted to include this image in electronic media. Please refer to the printed journal. Reuters
Most of the injured have relatively small cuts and abrasions caused by debris floating in the vicious tides. Prasad Kumarasinghe, a senior consultant dermatologist at Colombo North teaching hospital in Sri Lanka’s capital, says that sand and debris compacted in various orifices and complicated treatment. “By the time medical help arrived in some areas, many abrasions and tissue injuries were infected”, he recalls. “Cellulitis was common”, he adds. Chansak Wacharong was part of a small team of doctors dealing with orthopaedic trauma in Thailand’s Phang Nga province. “During surgical debridement we found extensive fat necrosis above and below the fascia of the muscle in most patients. All had greyish sand-like contamination that extended to more than five times the size of the initial wound”, he explains. Almost all of the patients treated and operated on during the first day, later turned out to be infected, requiring further debridement with the wound left open, Wacharong says. One-third of cases needed re-debridement due to further tissue necrosis. Pulmonary problems in survivors who nearly drowned were also common. Sri Lankan surgeon Abeygunasekera says several people required ventilatory support. “Deaths could have been saved if more ventilators were at hand”, he says. The widespread infection rates for injuries across the region put huge pressure on drug supplies in the first few days after the tsunami. All patients required large doses of antibiotics, which, according to one Sri Lankan doctor, was a hard target to meet considering drugs are not abundant at the best of times in Sri Lanka’s cashstrapped health system. Palitha Abeykoon of WHO in Sri Lanka says the initial pledges of medications were worrisome for local authorities because the country’s drug regulatory agency was not able to go through normal testing procedures for donated drugs. However, inital shortages of antibiotics, analgesics, infusions and surgical supplies have now
205
Treating the injured and burying the dead Doctors bore the brunt of the immediate relief effort across southeast Asia. While thousands of dead bodies piled up outside hospital buildings, surgeons worked tirelessly to treat those with infected wounds. Hannah Brown talks to doctors involved in caring for the tsunamis’ survivors.
Oxford Cartographers, 2005
“It was full of dead and dying people. Not a few, but hundreds”, recalls Seevali Tillakaratna, a surgeon at Karapitiya Teaching Hospital in Galle, Sri Lanka, one of the towns most affected by the devastating tsunamis that ripped through southeast Asia on Dec 26, 2004. From relative safety on a hillock near Galle, Tillakaratna remembers surveying the ruined town below. “The devastation was unbelievable”, he says. “Huge buses were toppled and most of the buildings were mere rubble.” In the hours after the waves came crashing into the shores of a dozen countries bordering the Indian ocean, doctors bore the brunt of the immediate relief work. Tillakaratna and his colleagues, like physicians all over southeast Asia, rushed to their hospitals and embarked on marathon shifts to treat the injured and deal with the dead. The huge numbers of dead bodies marked out this disaster beyond all others. Just 1 day after the tsunamis,
204
Karapitiya hospital was full of dead. Nearly 800 bodies were piled on the floor in the outpatient department building and the recreation hall of the psychiatry unit, explains urological surgeon Anuruddha Abeygunasekera, a colleague of Tillakaratna’s. “There were not enough refrigerators or even beds available”, he adds. Raja Sabapathy, head of the department of plastic surgery, Ganga Hospital, Coinbatore, India, says dealing with thousands of dead bodies was a situation for which he and his colleagues were least prepared. There were no stretchers to carry bodies or sheets to cover the rotting ones. “All of us gave money and planned for the living people, but nobody thought of the dead”, he laments. Fearful of disease being spread by bodies rotting in the tropical heat, people have been burying corpses in mass graves, or giving them temporary burials in an effort to delay the decaying
process. But relatives’ and survivors’ demands for identification of the dead mean clean-up activities come second to the massive forensic operation. Somboon Thamtakerngkit, of the Department of Forensic Medicine, Siriraj Hospital, Thailand, says 2 weeks on from the disaster, bodies are no longer recognisable. “Differentiation among western and eastern people was not too difficult in the early days, but now it has become hard”, he says. Thamtakerngkit says his department dispatched 52 volunteers to Phang Nga province, one of Thailand’s worst affected areas. The team recorded memorable features of the bodies, took tissue samples, and wrapped identification tags round the wrists of corpses. But the rapid decay meant the workers soon had to move on to taking samples of muscle and cartilage to ensure DNA tests could identify the dead, even after the body had decomposed. Dentists have become particularly valuable, especially in Thailand where relations of the foreign tourists involved are putting pressure on the country for proper identification of the dead. Kittipong Dhanuthai, a Thai dentist from Chulalongkorn University, who has been involved in the identification efforts, explains that all of the eight schools of dentistry in Thailand have sent teams to the coast to help x-ray the teeth of dead bodies, analyse filling material, and remove teeth for analysis. The team had just four mobile x-ray units for the thousands of bodies; although there were no lead aprons to protect the operators from radiation. Several doctors from the region believe the vast numbers of dead and the small numbers of major injuries in survivors are an indication that severely injured people did not survive the 20 min battering by the tsunami waves. www.thelancet.com Vol 365 January 15, 2005
World Report
www.thelancet.com Vol 365 January 15, 2005
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
abated, she says. The current priority is preventing emerging diseases. Much media attention has focused on the emerging threats of infectious disease spread through camps of people made homeless by the tsunamis. But according to AP Dash, a professor of medical entomology for the Indian Medical Research Council, the tsunami has had “no direct impact either on increasing or causing outbreaks of vector-borne disease”. He led a team in Tamil Nadu in southern India that conducted a survey of coastal areas affected by the waves to identify dengue vectors and other emerging diseases. He plans to re-survey the areas in the coming weeks. Aroona Abdulla, part of a relief team from the University of Colombo’s faculty of medicine, says patients with chronic diseases have largely been forgotten in the emergency. Many who regularly take medication lost their supplies in the waves, and were uncatered for in emergency relief packages. WHO is now emphasising that surveillance is the key to preventing major outbreaks in camps housing those left homeless. And while systems are up and running in Sri Lanka and Thailand, Indonesia is yet to establish a reliable reporting system. The damage to health facilities in Indonesia far outstrips that in other countries. A progress report compiled last week by NGOs working in Indonesia estimated that at least 77 health centres and eight hospitals were damaged. These numbers are expected to rise. The medical laboratory in Banda Aceh has been washed away; so, too, has the provincial health office. 50% of the health workers were dead or missing. As the need for emergency care recedes, the health needs of the population move away from acute care, according to Abdulla. Public-health support is now a priority along with educating local health workers about the management of tsunami injuries. Abdulla’s team from the University of Colombo has organised relief activities
for coastal areas, including provision of drugs and medical attention. The team is also helping to educate homeless populations on prevention of disease and hygiene, bringing some order to the disorganised initial activities. Even so, the impact of this disaster remains devastating. Many doctors worry that survivors who have lost everything will see no reason to go on. “There have been suicides already”, one doctor comments. “Let’s hope this nightmare is over soon.”
Hannah Brown
Rights were not granted to include this image in electronic media. Please refer to the printed journal. Reuters
Most of the injured have relatively small cuts and abrasions caused by debris floating in the vicious tides. Prasad Kumarasinghe, a senior consultant dermatologist at Colombo North teaching hospital in Sri Lanka’s capital, says that sand and debris compacted in various orifices and complicated treatment. “By the time medical help arrived in some areas, many abrasions and tissue injuries were infected”, he recalls. “Cellulitis was common”, he adds. Chansak Wacharong was part of a small team of doctors dealing with orthopaedic trauma in Thailand’s Phang Nga province. “During surgical debridement we found extensive fat necrosis above and below the fascia of the muscle in most patients. All had greyish sand-like contamination that extended to more than five times the size of the initial wound”, he explains. Almost all of the patients treated and operated on during the first day, later turned out to be infected, requiring further debridement with the wound left open, Wacharong says. One-third of cases needed re-debridement due to further tissue necrosis. Pulmonary problems in survivors who nearly drowned were also common. Sri Lankan surgeon Abeygunasekera says several people required ventilatory support. “Deaths could have been saved if more ventilators were at hand”, he says. The widespread infection rates for injuries across the region put huge pressure on drug supplies in the first few days after the tsunami. All patients required large doses of antibiotics, which, according to one Sri Lankan doctor, was a hard target to meet considering drugs are not abundant at the best of times in Sri Lanka’s cashstrapped health system. Palitha Abeykoon of WHO in Sri Lanka says the initial pledges of medications were worrisome for local authorities because the country’s drug regulatory agency was not able to go through normal testing procedures for donated drugs. However, inital shortages of antibiotics, analgesics, infusions and surgical supplies have now
205