Len Notaras

The Royal Darwin Hospital and the 2002 Bali Bombings

I originally wrote this on 12 October 2012, the tenth anniversary of the 2002 Bali bombings and I had it on the Old Yummy Lummy blog. I thought I should update the post a little and bring it over to my current blog. I’d welcome comments and feedback.


This post is not like my regular food posts. Today I’m recalling the memories and experiences from October 2002. This post is by no means a complete recollection, I don’t want to bore you with minutiæ, it may not even be the highlights, it’s more likely the things that come to mind as I write. I’ve decided against including clinical images. I realise most readers of this blog prefer to see food rather than burnt and traumatised human flesh.

Saturday night 12 October 2002

I attended a dinner meeting of the then Australasian College of Health Service Executives (now the Australasian College of Health Service Management). It was a good night, I spent time with my friend and colleague, Dr Len Notaras plus many others. [That had been a good year. On 20 May, I accepted Len’s encouragement to act as the Executive Director of the Royal Darwin Hospital (RDH) while maintaining my role as Supervising Pathologist and Director of Pathology for the Northern Territory Government. ]

That night in Kuta, Australians, other foreign nationals and the local people of Bali and Indonesia were enjoying a night out. Map http://goo.gl/maps/ZHdGP

While we slept in Darwin bombs exploded in Kuta. In the end, it’s thought 202 people died and another 209 people were significantly injured.

Sunday 13 October 2002

That morning the news services reported on the bombings. There was not a lot of information about the health needs that would be required for the people injured. A young man who was slightly injured managed to catch a flight from Bali to Darwin and he presented to the Emergency Department at RDH. He provided the first insight for us on what happened. Later in the morning I was receiving telephone calls that we needed to meet at the hospital because Darwin may be used as an entry point for the survivors who needed acute critical care.

My best friend, Dr Len Notaras, AM

Dr Len Notaras was meeting with Clare Martin, the Chief Minister of the Northern Territory who was in communication with the then Prime Minister of Australia, Hon. John Howard. Len provided reassurance to the CM and the PM that patients could be brought to Darwin and we would look after them.

Australian Defence Force reserves are amazing

At Richmond, RAAF flight crew were departing in a C-130 to pick up some of our doctors and assess the situation in Bali. The initial thinking was there would be a scoop and run operation of walking wounded (as opposed to stay and play). The early information was vague and inaccurate. We had a general surgeon (Dr David Read) and an anæsthetist (Dr Sue Winter) take satellite telephones with them from the RDH. These two doctors were reservists and full-time staff specialists at RDH. With our RDH telecommunications devices, we were able to collect raw information from the field. Such information proved invaluable and much more accurate when compared to information from official sources.

Getting together at the Royal Darwin Hospital

In the early afternoon, the hospital executive including senior clinical leaders met to discuss how we would manage patients being flown across. We didn’t know how many patients nor what condition they would be in. We called in a lot of staff, being careful not to call in into work the entire staff knowing this would be a multi-day campaign and we were conscious of fatigue. Many clinicians, pathology scientists, professional officers, administrative and general duties staff volunteered to help. I have memories of garden staff coming in to move equipment and patients as we decanted patients and equipment around the hospital, to the collocated Darwin Private Hospital and to home.

The RDH Boardroom which acted as our command and control centre. It’s not like the modern day room we have in the Australian Government Department of Health (Health).

Moving patients out to make space

We agreed to decant the two general surgical wards on the second floor, we got all the patients in the hospital in the know and many agreed to go home or somewhere else. We decanted the less sick patients who needed to stay to an old vacant cafeteria area. Some patients we had to force to stay, they wanted to leave to allow their place to be taken by a bombing victim. By the end we had discharged 100 patients to make room and to free up staff.

We moved high dependency patients to the co-located Darwin Private Hospital. We were lucky, we only had one patient in our Intensive Care Unit. We were lucky, Darwin was hosting a meeting of anæsthetists that weekend. We were lucky we had a reasonable amount of time to prepare.

Like any other hospital, despite making bed space available, we still had patients presenting to the ED to be seen. I recall one of my pathology staff fell from his bicycle and needed attention in the ED at the time. A young girl swallowed a fish that went down the wrong way and ended in her airway. She needed urgent attention while the ED went about quietly and calmly preparing.

By the evening we had the second floor clear, the medical wards had also reduced their patient numbers, the ICU had a single patient and we had kitchen and support staff in to keep the hospital going.

Accurate information makes all the difference

Throughout the night we received calls from Dr David Read and Dr Sue Winter who had flown to Bali with the RAAF. We were on the telephone with DFAT and other agencies. The then NT Minister for Health came through at 2100 ACST and she did a walk through with Len and me. We knew in the early morning the first flight would come in and then over about six hours we would receive all the patients. We knew some patients were also being flown to Perth. It was spooky walking through the empty surgical wards of a silent hospital.

During the evening a burns and critical care team from Adelaide arrived to assist. The team from the Royal Adelaide Hospital worked seamlessly with our staff. We had local General Practitioners volunteering to help.

Food, money and letters

It became known across Australia what we were preparing for and over the next thirty-six hours what we were doing. The news spread across the world. Within Australia, Australians were calling us and sending us food. One lady from Adelaide sent up a heap of pies by an overnight courier. Another lady rang a local Darwin pizza shop and sent pizzas.

In the weeks following I received letters from school kids from around the world. A bloke in Texas sent me hundreds of US dollars in notes and coins in an envelope.

Monday 14 October 2002 Bali bombings

The patients arrive

Over the Monday morning and early afternoon, four flights of RAAF C-130 Hercules flew in and brought patients to us with burns, trauma and high speed shrapnel and blast injuries. I remember the smell of the patients, the burnt flesh. I remember how they looked, the most severely burnt patient had no ears, lips or nose. I thought one patient who was being wheeled in in front of me was dead. Then his arm moved and I knew he was alive. He did not survive. I was in the ICU before he died. His bed was gushing with fluid that was coming away from him. We later learnt he wasn’t Australian, he was Greek. Our ICU team were able to make contact with his family in Greece. They were told in his last hours a hospital chaplain held his hand, spoke, sang and prayed with him as he died.

Surgeons and physicians working together in perfect harmony

If you’re medically or nursing qualified, the most fascinating and invigorating and spirit enhancing thing was watching specialist physicians, surgeons and their trainees along with other medical practitioners and registered nurses working together. I mean truly working together. The traditional medical referral system was halted for a day or so. Surgeons worked their science and art wherever they could. Debridement and fasciotomies were being performed in wards, corridors and operating theatres. Physicians were working as metabolic teams. They didn’t know their patients, there was no time and many of them were too sick for a relationship with their doctor. We enlisted medical students to ferry pathology results and assist in other very useful ways. The pathology and radiology areas were run ragged.

What about pathology, the heart of medicine?

I made time to visit Building 13, my building, the Pathology Department at RDH. My close colleagues in the laboratory, my friends were working frantically. Results were needed by physicians to stabilise and resuscitate patients. The hæmatology, chemical pathology and blood transfusion laboratory scientists were working around the clock.

An infection control and prevention nightmare of epic proportions

Over the days my speciality interest in Clinical Microbiology was needed. The hospital in Bali did a great job but they ran out of supplies and equipment early. To keep cool and to find relief, many patients before the burns took over were conscious enough to cool themselves with water from wherever they could find it. The water wasn’t always clean. Some patients were sitting in water. Bali is replete with multi-antimicrobial resistant bacteria. The patients’ burn wounds were being infected before they left Bali. We spread multi-drug resistant bacteria around Australia as we transferred patients around the country. We had introduced an infection control nightmare. I struggled to stay on top of that plus everything else. Fortunately, Darwin has the highest concentration of infectious diseases experts in the universe.

Rack, pack and stack

After all the patients arrived, the job was to assess, resuscitate and for the severe burns patients transport to a burns unit in another state.

With colleagues in Health in Canberra and the connections we had with the ADF, senior clinicians from RDH arranged for a milk run around Australia to transport burns and some trauma patients around the country. We did our best to place patients in their home state or territory. That couldn’t always happen. Their clinical needs were paramount. Some patients managed to get direct flights into Brisbane and Adelaide via other aeromedical evacuation (AME) services. I recall with some happiness seeing the Brisbane team arrive and recognising a senior staff specialist from the Princess Alexandra Hospital come and retrieve a couple of patients.

I can remember so many inspiring stories from the days and weeks afterwards. We had visiting dignitaries from within and without Australia. We received updates from burns bosses in the other Australian centres about the patients we shared, those summaries were shared with staff so they knew the destiny and outcome of the patients they got to know briefly but intimately. The cooperation amongst the burns units around Australia was great. There was a lot of information sharing between everyone.

Disappointment

It was about that time I applied to become the permanent General Manager of the Royal Darwin Hospital. I remember the disappointment of being turned down. May to December of 2002 was the most meaningful period of my career. I’ve done lots of other things and done things I’m proud of. The proudest career moments though for me were sharing time with everyone from Royal Darwin Hospital. Working with the best hospital staff anywhere on earth. I’m conscious that most people think their workplace, especially if it’s a hospital thinks where they work or where they trained is the best. I just know what I know and I’m happy with that thought to last me forever.

Mr Howard, OM, AC inspired the NCCTRC with Dr Len Notaras

Since then the National Critical Care and Trauma Response Centre has been established. I was there when it began and now I work in the Australian Government Department of Health and part of my job (from 2007 to 2012) was the administration of the funding agreement associated with the NCCTRC. I work with my friend and colleague Dr Len Notaras, AM just like I did when I was in Darwin. The icing on the cake has been the contract between the Princess Alexandra Hospital in Brisbane and the NCCTRC. I did the bulk of my medical and specialty training at PAH. It is fantastic to see them working together. RDH and PAH are my two favourite hospitals, the hospitals that built my career, the hospitals that made me the person I am, it is such a good feeling knowing they have a working relationship around trauma.

War and disaster conference 2012

Last weekend (remember I wrote this originally in 2012) from Thursday evening to Saturday evening I found myself in Darwin for the NCCTRC’s war and disaster conference. I had the best time. We had a dinner with Hon. John Howard, OM AC speaking about the Australian Government’s experience at the time of the first Bali bombings. The new Chief Minister Hon. Terry Mills spoke too. Kamahl was there too to entertain us. Len Notaras’s wife, Robyn Cahill also sang at the dinner. On the Friday we had a clinical symposium for the RDH and visiting PAH clinicians as well as some special guests like Dr Mark Little from Cairns Base Hospital. He spoke about the evacuation of the Cairns Base Hospital for Tropical Cyclone Yasi. On the Saturday we had a Clinical Conference which I spoke at. I also did some media. Here is a short clip of an interview. I’ve been told other aspects of what I said were reported elsewhere http://www.abc.net.au/news/2012-10-04/bali-bombings-doctors-warn-on-disaster-response/4295686?section=nt

You can’t get more Australian than a barbecue

Back to 2002. Move the clock forward four weeks and we had a barbecue. There was some criticism given the nature of most of the wounds were burns. We thought about it and agreed that the best way to thank the entire hospital was to hold an event revolving around food and letting everyone have some down time. A barbecue was still the best option. So in mid-November, Len and I and others from within the NT health bureaucracy arranged a huge staff barbecue. I cooked meat and happily fed the hungry. I remember Rodney, one of our groundsmen coming back four times. I remember that night arranging for platters to be delivered and for Len and I to walk through every ward and to speak with and share food with everyone on night duty.

The staff barbecue. I cooked lots of meat.

Honoured

Move the clock forward a year and some of us were included in the special 2002 Bali bombings investiture. I thought long and hard about it. Was I worthy. I wasn’t sure. I decided to agree to accept membership of the Order of Australia. Afterwards there was criticism. How did people get chosen? Why only so few? I queried whether I should relinquish my membership. I spoke with people close to me and I was reminded by so many that I represented the hospital, the people of RDH. Whenever I look at the lapel pin in my jacket or sign my name with the post nomials, I think of the victims and I think of the people at RDH. I try not to always think of the same person but to think about everyone I can remember from that time.

Move the clock forward and what have we done? We have the NCCTRC. We have the Office of Health Protection. We have the National Incident Room which I used to manage (2007 to 2012). We have national health emergency preparedness plans for mass trauma and other events. We have evolved. We have grown.

Inside the Aileen Plant National Incident Room.

Importantly the relationship between Australia and Indonesia has grown significantly. The relationship between Darwin and Bali has blossomed. The relationship between RDH/NCCTRC and Sanglah Hospital is fraternal and now involves regular staff exchanges. The relationship between the people of Bali and Australia has become intimate in so many ways. Whatever the motivation was for those responsible for the 2002 Bali bombings on 12 October 2002, the result has been a development of preparedness and response from the health sector and a closer bond between the peoples of two countries and two cultures.

Gary

Some extra reading

War and Disaster

Bali Honours List Below the list of the individuals honoured by Australia for their contributions in the response to the October 12, 2002, tragedy in Kuta, Bali.

In Honour of Some Heroes of this War (please read to acknowledge them as many have not)

The Darwin Hospital miracle

Full list: Bali honours

Sanglah General Hospital http://sanglahhospitalbali.com/v1/index.php

Map http://goo.gl/maps/dLw9v