The Bali bombings of 12 October, 2002: lessons in disaster management for physicians

Abstract

A little before midnight on Saturday 12 October, 2002, two bombs exploded in Bali nightclubs, resulting in death and injury to hundreds of people, particularly Australians. The subsequent 3 days saw a transformation of the Royal Darwin Hospital (RDH) as it received, assessed and stabilized over 60 critically ill patients. By 8am Tuesday morning, the majority of patients had been safely transferred out of Darwin to hospitals in their home state. We present in this overview, the role of physicians in this disaster and describe lessons learnt as we reflect on this event. Traditionally, physicians would not regard themselves as an important component of disaster management. The Bali bombings render this view obsolete. At RDH, physicians had been, happily, not a significant part of disaster management committees and planning. After all, what would those with expertise in cardiology, infectious diseases, nephrology, neurology, endocrinology, oncology and gastroenterology have to offer patients with burns, lacerations and other trauma? As the 60-plus patients rolled in and out of the emergency department (ED) on the morning of Monday 14 October − some to the intensive care unit (ICU), others to theatre and the majority to two hastily cleared surgical wards − most of us continued our clinics. That was until a surgeon on his way to theatre observed that his wards had become a de facto high-dependency unit and asked for physician input. As a group, an urgent meeting of physicians was held and two teams were created. Rosters were tentatively established, with some physicians released from usual ward work, others covering extra ward work, and some sent home with a view to a night shift. The teams regularly assessed all patients evacuated from Bali for the duration of what was to be a 24-h stay. Particular attention was paid to clinical assessment, haemodynamic and homeostatic states, dressings, analgesia and identification of early sepsis. Unwell patients were identified and further resuscitated. Those with severe deteriorating injuries were identified and transferred to ICU and patients were always medically stable for theatre at surgeons’ priority. Unrecognized injuries were detected. It became immediately clear that a disciplined (time consuming), ‘physicianly’ history and examination were indispensable. Patients were found to have unexpected injuries. Examples include a patient with multiple cerebral infarction in different vascular territories, another unable to speak or swallow due to a glass shard penetrating his vagus nerve and another with sciatic nerve injury. All patients suitable for transfer to other Australian hospitals were medically stabilized for travel as planned on the morning of Tuesday 15 October. The RDH involvement saw no medical mishap or preventable deterioration and all patients arrived at their home-state hospital safely. It was essential that Darwin was the ‘receiving point’ for Australia, despite being less resourced than other Australian cities. Close proximity to Bali was important, as indeed at least one person died in transit to Darwin and, despite the excellent effort of the Balinese hospitals, many still needed acute fluid resuscitation. Furthermore, it was equally important that there be early transfer to hospitals offering specialized care, especially burns units. No single hospital could realistically work at such capacity for a prolonged period and we were well aware that many of these patients would deteriorate (due particularly to sepsis, respiratory and renal failure) before they improved. Thus, there was an emphasis on rapid evacuation, which the Australian Defence Forces facilitated within 24 h. There are many lessons for physicians from the events of 14−15 October at RDH. The first relates to our old demon of undervaluing ourselves. In general terms, hospital-based physicians should see themselves as a sizeable and flexible group that is able to contribute in a variety of ways during a disaster. The need for ‘physicianly’ history and examination can be overlooked in a disaster situation involving large numbers of casualties. Furthermore, in disasters, physicians can be used for alternative purposes outside of hospital (i.e. triage and hospital liaison). Physicians should be central in coordinating the overall management of inpatient care as well as the logistics of who to transfer, where and when. This frees up the surgeons for the immediate surgical care of the wounded. Another very valuable lesson was found in the value of joint ward rounds. Surgeons and physicians rounding together was highly educational and enhanced patient care. In this disaster, we found that medical ‘political correctness’ was obsolete. Conventional hospital work has written and unwritten codes of behaviour, including consultation requests, communication and rules on who can order drugs, fluids and tests on another's patient. Heads of areas found themselves adopting a more military style of behaviour by asking or even telling colleagues to go and review a particular patient or relieve a particular doctor. Those receiving instruction willingly accepted directives. This was a time when repeated apologies, explanations and expressions of gratitude were not necessary. It was amazing that, when everyone was busy, confron­tations over medical jurisdiction of medicine, surgery, ICU or ED were absent. Another lesson is that doctors are just one small cog and perhaps receive an inappropriate share of the accolades. While nurses share a profile as patient-care providers, one can overlook the efforts of pathology technicians, radiographers, cleaners, ward clerks, security officers, kitchen staff, switchboard operators and a variety of members of the public, all of whom have made significant and essential contributions. Finally, we as physicians need to ask why this happened. Few commentators have maintained the less popular view that the root causes of the Bali bombings are not being addressed. Public and political rhetoric is more of revenge and intolerance. How do we engage our countrymen in reflection on Australian foreign policy, trade imbalances, poverty in developing nations, Middle East issues and so forth? The Bali bombings, we believe, had a great impact on RDH. The medical community collaborated and performed as if rehearsed for 12 October. The wider Australian community responded in a similar fashion. Interstate hospitals and colleagues in every state offered, unprompted, to be a part of the national response and were ready to receive patients for the longer term and definitive care. Government and non-government agencies (such as St John Ambulance), the Defence Forces and individuals worked together to manage an extraordinary undertaking and to deal with what was arguably the biggest post-war disaster to be met by Australian hospitals.