A diary from the U.S.N.S. Mercy: Health care after the tsunami

Matthew Wynia, MD, MPH, was on holiday in Oregon last December when a tsunami ravaged parts of Asia. Dr. Wynia, the director of the AMA Institute on Ethics and an assistant clinical professor at the University of Chicago, quickly decided to take action. "It dawned on my wife and me that I had something to offer."

His first step was to go online and begin looking for ways to help. He found Project Hope, the non-governmental organization into which the AMA later channeled its relief donations. At that time, the organization was seeking volunteers to staff a hospital ship. "A floating hospital," he said. "You park it offshore. What a great idea."

In March, Dr. Wynia found himself on that floating hospital -- the U.S.N.S. Mercy. He was one of about 200 U.S. health care professionals who volunteered to assist Project Hope in staffing the Navy's Operation Unified Assistance. As part of this two-month mission, which sought to restore hope to the region and demonstrate American good will, volunteers evaluated and treated more than 9,200 Indonesian patients and did more than 17,000 procedures.

His tour lasted 3½ weeks, during which time Dr. Wynia spent his days just off the coast of Banda Aceh, Indonesia, and witnessed the devastation wrought by the giant waves and the resiliency of the human spirit. This trip was not his first to the developing world. He also volunteered in Pakistan while doing his medical training. But this time his purpose was disaster relief -- and that is a very different experience, full of both rewards and frustrations.

During the Project Hope mission, Dr. Wynia kept in contact with his friends and family back home via e-mail. What follows are excerpts from these messages.

March 3: It is hot and lush at the Banda Aceh airport. The grounds are clean, though not immaculate, and the area is flat for several miles around. But apart from the medical aid tents and helicopters coming in and out, it is hard to tell that there has been an emergency. It is really only when we board helicopters for the flight out to the Mercy that we see the area destroyed by the tsunami. It is stunning, in the most literal sense of that word, and it left us all breathless and sad and quiet. The pictures on CNN can't really convey the size of the area affected.

Everyday: Normal and yet not

March 6: We are working in shifts, but everyone gets the same shift for the entire time we're here. For the doctors, we have overnight call, and mostly the work is very similar to what happens in a U.S. medical center, except that the whole medical center is rocking back and forth.

There are military docs who make triage decisions ashore about who gets to come aboard for treatment, then they are flown out by helicopter, along with a family member as an escort. Once they get here, they go through an ER-type set up, where they all get chest x-rays for TB, including the escorts, and then they are admitted to the ward or the ICU.

The medical care [on the ship] is really very good. The facilities are cramped but quite sophisticated. We have an amazing radiologist who can do interventional work and CT scans. We can do endoscopy, major orthopedic, ENT, general surgery, dental work, ophthalmologic surgery and other things. We have some limitations in our lab services -- no fancy serologies, for example -- and our pharmacy is obviously limited.

We're seeing a lot of very resistant bacteria. We've had E. coli bacteria sensitive only to imipenem and amikacin. But the major issue we are dealing with right now is how to take care of people who will need to go back to shore within seven to 10 days. That means no multistaged surgeries and no prolonged ICU stays.

We can't stay on longer for multiple reasons, not least of which is that the Indonesian government has said all military aid must be gone by [March] 26th -- roughly 90 days from the date of the tsunami -- and the people of Aceh want to be self-sufficient. There is a delicate balance between providing aid and being destructive of the local economy and local systems of care. In fact, this whole situation is just a lot more complex than I had realized.

March 7: I spent most of today with Dr. Nurul Machillah, the chief radiologist at Abidin hospital in Banda Aceh, and Dr. Maimunah, the head of pulmonary medicine there. They came out to the ship, interested in seeing where some of their patients had come for intensive care.

Dr. Nurul filled me in on how the hospital and her practice have been affected in the wake of the tsunami. There is no one who was unaffected. Even those we are caring for today on the ship, most of whom do not have illnesses directly related to the tsunami, must receive care here, miles offshore from their family and friends, because the local hospital is not yet completely back in operation.

The medical school in Banda Aceh was not hit by the tsunami, but about 70 students [of 720 total] are missing. [It also] lies not far from Abidin hospital, which was its major clinical teaching facility and which, at the end of the day on Dec. 26, lay under two meters of black, warm, sulfuric water.

March 8: I spent another day aboard the ship. It's strange. I expected to arrive here, disembark and see loads of patients with tropical parasitic diseases, but instead I'm spending days on board ship, and it's a lot like my clinical work at home.

The reason I'm spending so many days caring for the ship's hospitalized patients is that there are limited opportunities to get to shore. We have only four helicopters to support the entire operation, and flight hours are very limited in deference to local customs.

We had another visitor today -- Irma Risdiana, a pharmacist volunteer with the Indonesian Pharmacists Assn. She is Javanese and lives near Jakarta but has rotated through the Abidin hospital twice since the tsunami.

As you might imagine, they have received truckloads of donated medications -- some will expire very soon. We are trying to help them find other groups who might be able to use them. Most of the donations, however, were of meds that donors thought would be useful in the disaster. Now they have oversupplies of some acute care meds but severe shortages of some basic medications, such as for hypertension and TB therapy.

Close quarters, clinical challenges

March 9: We are taking care of all patients on two open wards. And since each patient comes on board with at least one escort, there have been quite a few twofers where the patient escort also needs medical care, but this is only discovered after he or she arrives.

One patient's escort speaks English fairly well and has been helping to translate. She is 22 years old and has been a big help throughout the ward. Three days after she arrived, however, she developed a set of itchy blisters on her back and chest. Now we have a possible outbreak of chickenpox. Fortunately, as in the States, chickenpox is very common here, so most adults will have had it already. But, among the kids, several are very ill. If they get chickenpox, it could affect planning for surgeries that they need and that they will likely not have another opportunity to get.

We have no varicella immune globulin on board, nor any vaccine. We do have some valacyclovir, which I have prescribed for a few kids who are at greatest risk and for whom a battle with chickenpox could be a life-and-death affair, because it could cost them a needed procedure. I know this is not an approved use for valacyclovir, but it seems like the safest available option. The other option is to watch, wait and hope.

We also have an incredibly photogenic 17-month-old boy who has a large scrape across his scalp. It has been open to the air to allow it to scab over, but it was failing to do so over several days, so we swabbed it two days ago. It is growing MRSA and two resistant gram-negative rods. So now he has a wound dressing on his head ... and we're watching everyone else for resistant Staph.

Several children also have scabies, and one has had lice, which were infesting a stuffed animal that she clung to as though it were her mother. I can only imagine how scary it must be for a 3- or 4-year-old to board a helicopter, fly out to a huge ship, have surgery done by a bunch of doctors and nurses who don't speak your language. ... The last thing we wanted to do was to take away her teddy bear, but it is full of lice.

March 13: By tomorrow, we will have no more patients on board, as we prepare to sail to Singapore and return home, so we have an increasing amount of time on our hands. For me, the frustration has been that even if we had to curtail our clinical activities, I would really have liked to have been able to establish some relationships with folks on shore. There is a medical school, the medical center, the various departments thereof and the Indonesian Medical Assn. I could have made contacts at all of these places that might have had some long-term impact. Now, if this is to happen, it will have to happen via e-mail from home -- negating the potential positive effect of having someone from the AMA here "on the ground" because, in fact, I have not been "on the ground," just tantalizingly close to the ground.

I should say this frustration is not unique to me. These volunteers are a tremendous set of doctors and nurses -- every one is really interesting and energetic, and many are leaders in their fields and at their institutions.

Don't get me wrong. This mission has been a success in many very important ways. Even though we couldn't bring as many patients out to the ship as we all would have liked, for those we did get to the ship, amazing things happened.

We've had some real saves. One woman had a sinus infection that was taking up an area the size of a baseball just behind her left eye, and compressing parts of her brain, causing blindness and for her eyes to bulge out. We did a CT scan, drained the sinus surgically, put her on antibiotics. She will survive. Her vision will not be normal, but it will improve. If she had not been able to get the scan, she would have died in the very near term.

And when we have gotten off the ship, we've been able to do good work on shore. The nurses have done some CPR training and other trainings at the local nursing school -- which will hopefully have a long-term impact. The dentists have worked like dogs on shore, pulling teeth right and left. And the same is true of the optometrist. He's given out more than 10,000 pairs of glasses, each one individually tested for the patient and some of them specially made in the ship's lab.

These accomplishments have real meaning. It is incredible to consider that this whole region of Indonesia, which is intensely Islamic, was entirely closed to foreigners before the tsunami. Now, as a result of humanitarian aid we and many others have brought in, it seems likely to have opened up to the United States and other Western nations ... and it is hard to know what all the benefits of that might be.

March 17: We are about to disembark the ship in Singapore, and will have about 24 hours here before flying out for home.

Note: Edited by staff writer Stephanie Stapleton.