Mercy for Banda Aceh
U.S. ship to provide full hospital services to tsunami-stricken area.
As Indonesians continue their struggle to rebuild their lives and communities in the aftermath of the tsunami that struck on December 26, 2004, they can take comfort in the fact that they now have access to a fully operational modern hospital. The USS Mercy arrived off the coast of Banda Aceh, Sumatra, on February 5, where it will stay, according to the ship's public affairs officer, Lieutenant Bashon Mann, "as long as the government of Indonesia needs us to remain in the area." The Aceh Province was one of the areas hardest hit, with more than 107,000 fatalities.
Mann explains that this humanitarian mission is a bit different from others that have involved the Mercy, in that the navy is partnering with Project Hope, a nongovernmental relief organization, to provide services.
"With doctors and nurses from . . . the navy and Project Hope [and the] U.S. Public Health Service (USPHS) as well," says Mann, "we have the resources to provide [more] health care." Health care personnel are providing services on board as well as on shore.
The Mercy has staff for 250 beds, but the ship can handle up to 1,000 beds. It also has 80 critical care beds, a fully equipped laboratory, pharmacy and radiology departments (including a computed tomographic scanner), 12 operating rooms, dental and optometry services, and physical therapy facilities. Among the 612 personnel on board, there are 83 nurses, with more on the way.
Lieutenant Commander Sean-David Waterman, BSN, RN, of the USPHS, has been deployed to the Mercy from Aguadilla, Puerto Rico, where he works in the Division of Immigration Health Services. He says shipboard nursing presents some unique challenges, such as "starting an iv when the ship's floor is rolling in the opposite direction." The creaking of the ship and noise from pipes take getting used to, as does the lack of windows. Waterman notes that they often take patients up on deck because the lack of windows can be disorienting. Waterman also reports that he is assisting a team from the United Nations Children's Fund (UNICEF) in assessing the sanitation and health facilities of the temporary camps and evaluating the camp population for health problems. Diarrhea and respiratory problems seem to be the most common issues.
Lieutenant Commander Tom Pryor, BSN, RN, a USPHS nurse who usually works in the ICU at Phoenix Indian Medical Center in Arizona, writes that "tsunami pneumonia" has emerged as a significant clinical problem because so many people aspirated bacteria-contaminated floodwater. Another problem that surfaced recently is mucormycosis, a life-threatening fungal infection (see Mucormycosis Reemerges, page 34). What strikes Pryor, though, is how the Indonesian people are trying to continue with their lives. For many that means a life with far fewer family members and friends. Many, he says, are moving inland to other parts of the country, with no plans to return to lives that centered on fishing and the sea. For one teacher in Banda Aceh, only 11 of the 41 children he had before the tsunami have returned. (UNICEF estimates that of the people killed, one third were children.) Pryor's ongoing journal of his experiences can be found at http://www.surgeongeneral.gov/journal.
According to the final report from the World Health Organization (WHO) interagency rapid health assessment team (34 people from local Indonesian governments, the U.S. military, the Centers for Disease Control and Prevention, the United Nations, the WHO, and nongovernmental organizations who assessed and monitored relief responses in the first four weeks), better coordination is needed among all the agencies dispensing aid, and they need to start transitioning management to the local providers. The priorities now include restoring community health centers (puskesmas, "the backbone of the public health system"), providing care to new mothers and infants and the approximately 40,000 pregnant women left homeless, and rebuilding sanitation facilities and roads.
Rebuilding the basic infrastructure has been estimated to take one to two years, though that may be an ambitious estimate for Banda Aceh, where the mayor estimates that 40% of municipal workers died and 90% of public buildings were damaged. For now, though, they rely on Mercy.
Mucormycosis Reemerges
A threat in the tsunami zone-and beyond.
Another threat has emerged for those who survived the Indian Ocean tsunami in December 2004. On January 27 the Lancet reported that a 56-year-old male survivor from Australia is being treated for mucormycosis, a deadly fungal infection. He received deep wounds to his right thigh and hip and multiple lacerations and abrasions when the wave drove him through the walls of his hut, dumping him in a paddy field more than half a mile away. After initial treatment at a local hospital in Sri Lanka, he was transferred to a hospital in Sydney, Australia, where, despite multiple debridements and antibiotic therapy, the necrotic infection in his wounds worsened.
Mucormycosis is an invasive, rapidly progressive fungal infection of the Zygomycetes class that usually infects people with poorly controlled diabetes or who are immunocompromised. The most common sites involved are the sinus and nasal mucosa, where infection quickly spreads to the orbit and brain. Cutaneous mucormycosis, a form that does occur in the immunocompetent, is usually the result of contaminated traumatic wounds. Mortality rates are high-20% in cases of cutaneous infection and up to 80% in cases of rhinocerebral infection and disseminated infection.
Early diagnosis is essential because effective treatment requires urgent, and often radical, surgical debridement of all devitalized tissue. Along with surgery, high-dose amphotericin B (Amphocin and others), currently the only antifungal known to be effective against the Mucorales fungi, is administered. Hyper-baric oxygen therapy has been reported to be effective in some cases, but more studies are necessary before it becomes a standard of care.
Health officials are concerned that the disease could be devastating in areas affected by the tsunami, where many of the survivors who suffered traumatic injuries are at risk because infections and inadequate nutrition have undermined their immune systems. Diagnosis could be delayed or missed because the specialized laboratory equipment needed to analyze tissue samples is unavailable.
The Australian patient responded to treatment with extensive debridement of the infected wounds, iv amphotericin B, and hyperbaric oxygen. At the end of January he was still recovering in the hospital.