EDITOR’S NOTE: After the Dec. 26 tsunamis swept
a deadly path through south Asia, Dr. Robert Lorenz ’68, a
maternal-fetal medicine specialist in Michigan, looked for a way
to help. He soon found it through Project HOPE, a health education
and humanitarian assistance organization based in Millwood, Va.
Beginning in early February, Lorenz was one of 93 medical volunteers
on the U.S. Navy hospital ship Mercy. The USNS Mercy served off
the coast of Banda Aceh, located on the northern tip of Sumatra
that was severely affected by the disaster. Lorenz stayed in contact
with family and friends via e-mail. Following are excerpts from
Feb. 3, 2005: Questions
Greetings from the USNS Mercy Hospital Ship near Banda Aceh, Indonesia.
It has been a busy week traveling, assembling the complex team and
preparing the medical and surgical services. We still haven't seen
a patient; maybe soon. We have been oriented to shipboard life,
Navy medicine, tropical diseases and preventive measures, man overboard,
fire, and abandon ship drills. We have met our Naval counterparts
and support team and reviewed equipment surgical supplies, laboratory
and radiology services. Someone asked me a few weeks ago: Where
are you going and what are you going to do? I said I didn’t
know for sure. The answer is the same today.
Feb. 07: Busier each day
Well, we finally truly are a floating hospital – we have
patients! Children and adults, medical and surgical cases, all brought
in by helicopter from shore. We are getting busier each day, and
there is a lot to do on shore. The hospital there is a mess: Parts
of it are still buried in mud, the staff is exhausted, supplies
are limited, and they don’t have all services functioning.
One team went today and vaccinated hundreds of kids (for rubeola,
measles) in three schools.
The German hospital ship arrived here in early January from the
Iraqi theater. There is a group of Australian and New Zealander
medical military active on shore. All of them are based at the hospital
described above. Tragic story: All the patients were on the first
floor, approximately 100. They all died, along with two-thirds of
the medical and nursing staff. The first floor was buried under
feet of mud. Some wards have been dug out and some bodies removed.
Still, there are hundreds of bodies being found daily in the town.
The hospital has an ICU that is running, but we have already moved
some of the sicker patients to the ship. The province of Aceh had
a population of about 4 million; it is estimated that at least 400,000
are displaced from their homes.
There are about half a dozen Navy ships steaming around out here;
some supply our helicopters. The weather is warm, 80 to 90 F., with
90 percent humidity, but usually a wind. The ship is air-conditioned.
From the ship one can see the mountainous terrain. From miles out
it is clear that the shoreline is denuded as if a paintbrush swept
a mud colored stripe between the sea and the trees.
Superbowl Sunday was actually Monday 0600 hr. Lots of Boston folks
here celebrated with orange juice and pancakes.
Saturday, Feb. 12, 2005: “Semper Gumby”
Finally I got ashore yesterday. The motto of the mission, which
is applicable to everything we do, is “Semper Gumby”:
Be flexible. My assignment was to assist the OIC (Officer in Charge)
of the team going to the hospital by triaging patients for possible
transfer to the Mercy. The hospital is a series of one-story buildings
in a compound connected by covered walkways (to keep off the blazing
sun and the heavy rains).
The cases are incredible to someone who hasn’t done relief
work. The Germans have treated 28 cases of tetanus. The disease
causes progressive severe muscle spasms which resolve over weeks
but can be fatal due to respiratory failure, aspiration pneumonia,
etc. Treatment is muscle relaxants and tracheotomy and ventilator
support. Most wards have active TB cases. Lots and lots of fractures
– some from the tsunami with complications and more now from
“Moped meets Truck” events since then. “Tsunami
lung” is aspiration pneumonia which can be due to bacterial,
fungal, protozoal organisms or mixtures. The tetanus is quite a
story showing the value of immunization. Indonesia began neonatal
tetanus vaccinations about 20 years ago. Basically all the patients
with tetanus in the province are over 20! Immunization works.
The USNS Mercy now has about 60 patients, which is about the limit
of our provider team, given the severity of illness.
Feb. 15: Study in contrasts
The USNS Mercy Maternal Fetal Medicine consultation service was
fully activated on Valentine’s Day. We were asked to consult
on OB patients on the Australian and German units at the AZ hospital
in Banda Aceh.
By the time we arrived in early February, the hospital was a schizophrenic
combination of pristine, sparkling inpatient care areas staffed
by the military teams, and untouched areas of discarded medical
equipment, mud, tsunami debris, and foul standing water perfect
for breeding Dengue and malaria mosquito populations. The hospital
is secured by a perimeter controlled by the federal Indonesian military.
As of this date, the unit assigned to the United States is an empty
building with mud removed from the inside but not the outside and
a very happy and active mosquito population as the only inpatients.
The sewage system is inoperative in the whole complex; the water
supply is intermittent and of very questionable quality. Virtually
all the medical equipment, ventilators, anesthesia equipment, hospital
beds, and laboratory equipment was destroyed by the flood and the
mud. Piles of equipment provide scenic background to the landscape
devoid of vegetation.
Feb. 20: Young patients
The first patient on the USNS Mercy we will call Wahyu. The 11-year-old
boy came to the emergency room at the Banda Aceh hospital with a
two-day history of nausea, vomiting, abdominal pain, a fever of
104 F., and hypotension. The diagnosis was appendicitis, and surgery
was recommended. But in a tsunami-ravaged health care system there
was only one functional operating room, and it was busy with a complex
trauma case. It would be hours, and the boy was unstable.
By chance a medical team from the newly arrived USNS Mercy was
nearby, about to board their helicopter. In minutes the boy and
his father were taking their first flights. The diagnosis of ruptured
appendix was confirmed at surgery, and after a few rocky days he
fully recovered. His dad slept on the floor next to his bed in the
open ward. Dad declined the mattress nearby, but welcomed the three
hot meals a day. In Indonesian hospitals the family does a lot of
the care and is expected to provide food. The nurses go home at
night in many Indonesian nursing units. Medication administration
is intermittent or nonexistent, depending upon staffing and availability.
The hospital on shore had received its year’s supply on Dec.
20. The pharmacy was destroyed in the tsunami. Some relief medical
supplies have been received.
Many more kids joined us. A 9-month-old infant with vomiting and
diarrhea and a fever which was unresponsive to treatment at a field
hospital in Lamno, a small town down the coast. The hospital had
limited laboratory and radiology support. The visiting USNS Mercy
team identified severe hypotonia, a “floppy baby.” Concern
about meningitis and other life-threatening conditions prompted
transport by helicopter to the ship. Workup there revealed an easily
reversible condition: severe hypokalemia [potassium deficiency].
In retrospect, the prior treatment did not include replacement Kcl
[potassium]. This was probably the most expensive set of serum electrolytes
ordered in history!
Lots of pneumonia in the kids. “Tsunami lung” is the
label we have given to patients who developed pneumonia after ingesting
seawater and mud and God knows what organisms with the tsunami.
It is standard therapy in this part of the world to give a few days
of antibiotics (available over the counter usually), which are stopped
when symptoms improve but before full treatment is complete. A team
visited the hospital on shore and saw one child with persistent
respiratory failure die despite full therapy. In the next bed was
Igbad, a 12-year-old also doing poorly on a ventilator. He was airlifted
and was critical for days on a ventilator, but slowly got better.
The story was that he lost his parents and his brothers. His uncle
found him floating on a log two days after the wave hit. He now
is starting to walk a few steps. Unfortunately, other kids have
the complication of sepsis and neurologic findings from brain abscesses
secondary to tsunami lung. Hopefully they will improve with long-term
Patients and families fear coming to the ship. To leave land and
go to the sea where all the dead people have gone is a real test
of trust in the medical visitors. Each helicopter transport lifts
off leaving groups of tearful families waving to sick loved ones.
Many people have fled to the mountains and fear returning to Banda
Aceh ever again. They fear another wave. A few days ago there was
a 6.0 earthquake in the area. Buildings shook; the ground rocked.
Onshore families stampeded out of the emergency room. Fortunately
there were no injuries.
Each patient can bring one family member on board. We have open
wards, with family members sleeping nearby. When the nurse or doctor
and the interpreter visits a patient (here or onshore) a crowd of
onlookers gather. Informed consent is a group undertaking with neighbors
commenting, asking questions, and being very supportive. Patients
share stories and provide help to each other. Indonesians, despite
all they have suffered, are gentle, friendly, loving, and very appreciative.
They are also resilient. One said, “We will be OK.”
When they are discharged to shore, there are many tears of thanks,
and kissing of hands.
One of the most common admissions is for poorly healed femur fractures
from the tsunami. The Australian team has orthopedics, but no equipment
for femur nailing. These are treatable, and the most common tsunami-related
cases we see on board.
We have seen many large tumors that obviously had had no treatment
until our arrival. These people are poor and have not gotten care.
After the tsunami, the government declared that health care would
be free for an indeterminant time. People have walked, mopeded,
and bicycled from the mountains seeking care for untreated conditions.
Many come to the ship for CT scans. The unit on shore was destroyed
in the flood. Our radiologist is great, working long hours. Unfortunately
we find cases that are too far gone, and nothing can be done. The
families are very accepting and thankful for the information. They
seem to accept death more easily than we do.
In Ward One there is a kids’ playroom. Kids of all ages
have drawn pictures that are powerful statements about what they
have been through. Hopefully the safety of the ship, good meals,
medical treatment, and caring staff and family can help them physically
and emotionally put their lives back together.
Feb. 26: Force protection
Most of the civilians had never seen an M-16, or a 60 mm machine
gun, up close before. The Masters at Arms carry the M-16s. Three
60 mm machine guns are mounted on the deck. We can now report not
only do they look impressive, they are very loud. From two decks
away within the ship, the bulkheads rattled to the sharp volleys
of target practice.
In wartime, the Geneva Convention dictates that medical facilities
are to be clearly identified, and should not be attacked. It also
requires that medical facilities are unarmed. But we are not at
war in the waters off Sumatra. We are here to help. An 894-foot
U.S. Navy ship floating near the largest Muslim country in the world
in 2005 is highly visible. That is one reason we are here –
to show the good will of America to the victims of the recent tsunami.
But aid workers around the world have been targets of terrorists.
Federal regulations require that all military and civilian personnel
assigned to such activities undergo “Force Protection”
orientation. The story of the USS Cole bombing in Yemen was recounted.
We were instructed to watch out for unusual activity in the water
around the ship or while onshore. Onshore we were issued radios
and given assigned times to report. We were to report where we were
going, to stay with a buddy, and to stay within the hospital compound,
which was secured by the Indonesian military.
Soldiers with M-16s patrol the deck carrying binoculars, night
vision goggles, and radios. Fishing boats are watched closely. One
day, the shore team noticed an alarming absence of women and children
around the hospital, often a sign of impending trouble. The same
morning an unusually large number (eight vs. the usual two or three)
of fishing boats were in the area. Overhead, we heard: “Bridge
to security, boat fast approaching starboard bow.” I reached
the deck a few seconds later, and the boat had already passed the
bow to the port side. It kept motoring off into the open sea. The
ship’s horn blasted. Overhead: “Translator report to
the bridge.” Then more boats appeared, none getting closer
than a few hundred yards. An Indonesian military patrol boat with
a big gun on the foredeck appeared and hovered near a few boats.
Our ship is three football fields long. Two soldiers with M-16s
and one patrol boat didn’t seem like a good match for eight
fishing boats playing a shell game.
Maybe we just stumbled into the best fishing spot of the day.
Maybe they were trying to get a sick relative on board, although
we have never received patients by boat, or maybe not. The fishing
boats dispersed. We went to lunch.
March 3: Final report
One helicopter, one C-130 military transport plane, two bus rides,
one hotel night, 22 hours in three commercial flights, one car ride:
HOME! Other than being 12 hours displaced biologically, I am doing
fine. Many thanks to all for the good wishes, help at work and at
home, and prayers over the last five weeks.
The deployment of the USNS Mercy/Project HOPE task force is not
without cost to the Navy and to Project HOPE. However, the message
is more powerful and hopefully more effective in the battle for
the hearts and minds of the world. Military deployment and volunteer
health care providers providing disaster relief, humanitarian aid,
or health education represent an America we can all support. We
believe in individual freedom, the value of each life, and dignity
for all. We are a generous people, as evidenced by the charitable
contributions of our citizens for tsunami relief. Many Indonesians,
including some national leaders, fondly remember the visit of the
original SS Hope hospital ship to their country 45 years ago. That
was their first contact with Americans, and to this day it is part
of their view of our country.
It is hard to be portrayed as the bad guys when we are seen caring
for sick Indonesian children or helping midwives provide safer methods
of birth. If the world’s primary image of America’s
foreign policy were a huge white hospital ship rather than a Kevlar
helmet, we would be on the way to a safer world – Robert P.
Lorenz ’68, M.D.