AAOS Bulletin - June, 2005

Orthopaedists help tsunami-ravaged hospitals, victims

By Carolyn Rogers

On Dec. 26, 2004, the world was shaken by the stunning news that thousands of people had lost their lives when a tsunami of historic magnitude slammed into coastal areas of Southeast Asia. Over the ensuing days, as the staggering death toll continued to rise, people around the world were moved to donate billions of dollars to the relief effort

Many physicians wanted to help in a more personal way, but the question was how? Calls and e-mails to overwhelmed relief agencies often went unanswered, and bureaucratic red tape hindered many ad hoc efforts. Scores of would-be volunteers were left on the sidelines, feeling powerless to help.

In spite of the obstacles, however, many orthopaedic surgeons did manage to play a role in tsunami relief efforts. Following are the stories of two AAOS members who, through perseverance, found a way to help.

In Banda Aceh, Indonesia, the tsunami picked up fishing boats and dropped them several miles into the heart of the city

SIGN orthopaedists aid tsunami-damaged hospitals

One orthopaedist remains to serve 4.5 million in Aceh, Indonesia; Damaged hospitals in desperate need of equipment, supplies

One of the areas hardest hit by last year’s devastating tsunami was the Indonesian province of Aceh, on the northern tip of the island of Sumatra. More than 100,000 people perished there when a 9.0 magnitude earthquake off the coast of Aceh sent an enormous tsunami crashing into the province.

Lewis G. Zirkle Jr., MD, founder of the Surgical Implant Generation Network (SIGN)—a humanitarian organization dedicated to creating equality of fracture care throughout the world—has been deeply involved in relief efforts in this area.

“What is expected of me? What is demanded of me?”

When Dr. Zirkle thinks back to the day the tsunami struck, he recalls a quote by Abraham Heschel:

“Over and above personal problems, there is an objective challenge to overcome inequality, injustice, helplessness, suffering, carelessness, oppression… There is a question that follows me wherever I turn. What is expected of me? What is demanded of me?”

“Such were the feelings at SIGN following news of this horrific event,” he says. “We heard the stories of this tragedy and wondered how we could assist our fellow human beings.”

With ties to Indonesia stretching back 30 years, Dr. Zirkle felt especially close to victims in Aceh and elsewhere in the island nation. This special bond dates back to 1973, when he traveled there to train the first four orthopaedic surgeons who would practice in Indonesia. In the 1980s, he spent several years in the country training more than 50 orthopaedic surgeons and establishing four training centers.

Dr. A. Azharuddin stands next to a portion of his library, which was totally destroyed

Initially, Dr. Zirkle and SIGN Executive Director Jeanne Dillner volunteered to travel to Indonesia with an International Medical Corps team. When that plan fell through, Dr. Zirkle contacted former colleagues throughout Indonesia to find out where SIGN might be of assistance. He was directed to Dr. A. Azharuddin—the only remaining orthopaedic surgeon in Aceh, a province of 4.5 million people. After corresponding with Dr. Azharuddin, Dillner and Dr. Zirkle boarded a plane for Jakarta, Indonesia, along with 300 lbs. of equipment. Another 400 lbs. of donated implants and instruments were shipped separately.

Worse than a war zone

Dr. Azharuddin met the two in Jakarta, and the group traveled together to Banda Aceh, said to be the “ground zero” of the tsunami disaster

“Despite the news reports and pictures, one cannot be prepared for the situation in Banda Aceh,” Dr. Zirkle says. “It was like a war zone, except that in no war zone would the destruction be so complete.”

An estimated one-third to one-half of Banda Aceh’s population was killed in the deadly tsunami. All of Aceh’s main hospitals were devastated and thousands of medical providers were killed, including 75 of 100 nurses in Dr. Azharuddin’s hospital.

Dr. Azharuddin and his family escaped with their lives, but little else. He lost his home and possessions, and the hospital where he served as head of orthopaedic surgery and emergency care—Zainoel Abidin General Hospital—was ravaged by floods. When the water receded, the floors were covered with more than six inches of mud and debris, and critical equipment and supplies were in ruins. All of the hospital’s orthopaedic equipment, which Dr. Azharuddin had paid for with his own money, was destroyed.

“A spirit of cooperation and caring”

Even four weeks post-tsunami, “None of the hospitals were capable of doing surgeries,” Dillner says. “Their first priority was to find all of the people who were still alive, and to keep them alive. Only after that could they focus on restoring the hospitals.”

Dr. Zirkle worked at a Danish Civil Defense mobile unit for four days, performing wound debridement, external fixation and treatment of fractures that occurred after the tsunami.

One morning, the group attended a meeting of organizations that wanted to help rehabilitate the province’s main hospital. “A spirit of cooperation and caring filled the room,” Dr. Zirkle recalls. “The Germans took the lead in technical and administrative tasks, and the Australians were running a clinic that included OB/GYN surgery. China, Turkey, Malaysia, the United States, Singapore and medical teams from elsewhere in Indonesia were also represented.”

After a week or so in Aceh—where they slept on the floor of an Army barracks—the trio returned to Jakarta to perform SIGN surgery at Fatmawati Hospital. They were fortunate that Fatmawati’s senior orthopaedist is one of the four original surgeons that Dr. Zirkle trained back in 1973.

At Fatmawati, Dr. Zirkle worked with Dr. Azharuddin and several residents, performing SIGN nail fixation of tibia, femur and humerus fractures. The surgeons quickly became proficient at the SIGN technique, and SIGN equipment sets were given to Dr. Azharuddin and to Fatmawati Hospital.

“The SIGN system is uniquely qualified to treat patients who have been injured in developing countries because the system can be used without a C-arm and other equipment in the operating room,” Dr. Zirkle explains. SIGN is an all-encompassing system in which training, hardware, repeat visits and a continuing supply of surgical implants are provided free to host surgeons, enabling them to provide quality fracture treatment for the poor.

“We have great respect for the surgeons in developing countries, both in their personal surgical abilities as well as their perseverance in working under difficult conditions,” he says. “We don’t go there to ‘teach,’ but to interchange ideas.” 

Orthopaedic instruments, supplies needed

By mid-March, Zainoel Abidin Hospital had partially reopened, with three operating rooms (out of 10) functioning. Dr. Azharuddin shares the OR space with surgeons of other specialties, and is allowed only one surgery per day.

“Dr. Azharuddin faces numerous challenges, but has great determination to continue to assist his people and to continue teaching at the university in Aceh, which lost the majority of its faculty to the tsunami,” Dr. Zirkle says. “He is uncomplaining, yet we see the tension on his face.”

Dr. Azharuddin needs all types of equipment and supplies.

“There is a need for both orthopaedic and anesthesia equipment—anything that can be used in the operating room, or in an orthopaedic practice,” Dr. Zirkle says. “Computers, books and other teaching aids are needed as well. We have high hopes that the orthopaedic community will provide assistance.”

After the floods receded, Zainoel Abidin Hospital floors were coated with six inches of mud and debris.

A local volunteer walks past the Danish Civil Defense mobile unit where Dr. Zirkle worked for several days

A second hospital in Aceh has recently been restored and is almost ready to open its operating rooms. SIGN is trying to supply this hospital with equipment as well, so donated instruments will go to one of two hospitals in Aceh.

Calling all trauma surgeons

As the sole orthopaedist for more than 4 million people, Dr. Azharuddin is extremely busy and needs active orthopaedic surgeons to help him—trauma surgeons in particular.

Experienced trauma surgeons who are willing to volunteer their services for a one-to-two week visit, or anyone who wishes to donate equipment and supplies should contact Dr. Zirkle at (509) 371-1107 or at signcom@sign-post.org.

SIGN surgeon Anthony Brown, MD, traveled to Banda Aceh to work with Dr. Azharuddin in mid-May. In late June, Dillner and Dr. Zirkle look forward to returning to Jakarta and Aceh to bring more supplies, perform more surgeries and offer their support to Dr. Azharuddin. They also plan to start more SIGN projects in Banda Aceh and Jakarta, with possible extension to other cities.

For more information on SIGN visit http://www.sign-post.org

Tsunami relief: One doctor’s quest

Editor’s note: This report is based on an in-depth account of Dr. James A. Shaw’s experiences in Phuket, Thailand, which will appear in The American Journal of Orthopedics.

In late December 2004, news of the unimaginable destruction and loss of life wrought by the tsunami in Southeast Asia elicited an unprecedented outpouring of compassion and good will from people and nations around the world. Many individuals sought to help in a more direct way, including James A. Shaw, MD—a Md.-based orthopedic surgeon with fortuitously planned vacation time. Eager to join an organized relief effort, Dr. Shaw initiated multiple phone calls and e-mails to various relief agencies. His efforts, however, led to nothing but red tape, flat-out rejection or no answer at all.

By New Year’s Eve, a discouraged Dr. Shaw sat flipping the channels on his TV remote when the image of a local dentist of Thai descent flashed on-screen. The woman was soliciting medical volunteers for a relief mission to Thailand. A quick phone call introduced him to Dr. Usa Bunnag—“one of the most remarkable people I’ve ever had the privilege of knowing,” Dr. Shaw says. Dr. Bunnag emigrated from Thailand to the United States as a teenager. After establishing a thriving dental practice, she founded a charitable dental outreach program in Thailand, called Smile on Wings (http://www.smileonwings.org).

Within days, Dr. Bunnag had organized a nine-person medical team, donations poured in from local citizens and medical supplies were purchased through a local hospital.

The team left Washington, D.C., on January 9, 2005, bound for Phuket—a resort island province at the southern tip of Thailand that was badly damaged by the tsunami. Their mission was to provide health care for displaced persons at Bang Muang refugee camp in Khao Lak.

Upon their arrival, the group was given a tour of the damaged coastal area of Phang Nga province north of Phuket. “Huge hotels had been reduced to rubble, fishing villages were decimated, abandoned cars and trucks were bent and twisted … An eerie sense of death was everywhere,” Dr. Shaw recalls.

By the time they arrived, two weeks post-tsunami, most of the acute medical issues had already been addressed. Much of the team’s medical expertise was not in high demand, nor was there much need for the medical supplies they’d brought.

What was needed was routine primary medical care at the many refugee camps. “So I dusted off my stethoscope and honed my otoscope and tonsilar examination skills,” Dr. Shaw says.

The team spent most of its time at a large refugee camp that housed 855 families and about 3,500 displaced persons, near Bang Muang. They worked out of a large inflatable “hospital” tent, donated by a Japanese medical team.

“Many of the camp residents had sustained minor lacerations and abrasions during the tsunami, so there was a steady stream of bandages to change and superficial wound debridements to perform,” he says. “Although infrequent, there was some ‘real’ orthopaedic work to do, as well. I drained two paronychia infections and sutured a number of acute lacerations sustained during the camp construction work. A septic child with an infected ankle was triaged rapidly to the local hospital, as was a young man with a flank contusion, hematuria and peritoneal signs.”

Dr. Bunnag kept busy “24/7,” Dr. Shaw says. When she wasn’t extracting rotten teeth, she was organizing non-medical relief efforts. After locating an orphanage that had taken in many children whose families were lost in the tsunami, she donated a substantial portion of the group’s discretionary funds to their care.

Dr. Bunnag also learned of a decimated fishing village whose residents were living collectively in a local school and, to date, had been largely overlooked by formal relief efforts. After touring the area, she gave a small monetary contribution to each affected family. “Tears flowed on both sides of this wonderfully personal exchange,” Dr. Shaw recalls.

Later, when Dr. Bunnag learned that the children of this village had lost all of their bicycles, she placed a few quick phone calls. In little time, she had located and purchased bicycles for all, but then faced the seemingly insurmountable challenge of how to transport the bikes to the remote village.

“Again—not a problem for this remarkable woman,” Dr Shaw says. “She spoke to local military officials and charmed the commanding officer into joining us for dinner and providing a military vehicle and driver to transport the newly purchased bicycles the following day.

“I suspect that she performed many other good deeds of which I am totally unaware,” adds Dr. Shaw. “It was a privilege to play a small role in her mission.”

Effective relief missions require careful planning

While much good was accomplished, “As a group, our medical skills were underutilized, primarily because of a lack of acute care need in the area we served,” Dr. Shaw admits. “Dispirited individuals and medical teams circulated through our tent on a daily basis, almost pleading for something to do. Many groups also brought bags of equipment and supplies, which were left unopened in the storage room of the medical tent…It may be that the distribution of charitable goods, money and reconstruction services are best left to the professionals.”

However, Dr. Shaw believes a few operational “pearls” can be garnered from their experience. “Most importantly, an accurate understanding of current needs, native language skills, proper credentialing and official sanction appear to be prerequisites for a successful relief mission,” he says. “Our privately organized group was able to contribute in a meaningful way solely because of Dr. Bunnag’s established connections to national and regional medical officials, coupled with her local cultural identity and language proficiency. Of added bonus were her personal energy, tenacity and charm, which helped transform opportunity into meaningful service on many occasions.”

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