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Web Exclusives: PawPlus April 6, 2005: Ship
of Mercy 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 his reports: 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 antibiotics. 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. EPILOGUE 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.
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