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Editor’s Note: Dr. Jim Ireland had the opportunity to interview Dr. Sara May this week about her team’s experience as one of the first foreign medical aid groups to reach the scene of devastation in the typhoon-ravaged Philippines. Medical relief groups are now pouring into the region and Ohana Medical Mission from Hawaii will be there next week. You can read Ireland’s report on that here.

Two days after super Typhoon Haiyan flattened the Central Philippine Islands of Visayas, the team from California landed in Manila.

From there, they were transported by ground to a nearby military base where they were flown by the Philippine military to Tacloban airport on Leyte Island. At the airport, they were met by the Mayor of Tanauan, who had ridden a bike over 10 miles to seek help in the larger city. From the airport, they were ferried by military helicopter to a beach near Tanauan, Leyte.
As the helicopters landed, they were immediately surrounded by desperate residents in search of food and water.
Tensions were high as the storm ravaged residents did not initially understand who was coming and what they carried.

“Where are the body bags?” someone from the crowd asked, “We need body bags. Where is the food and water?” As the crowd came to understand that this was an American medical team, tensions eased.

Now dusk on Sunday, the team hiked into town to set up an emergency clinic at the nearly destroyed town hall. Arriving there at 7 p.m., they immediately began setting up in near total darkness and intermittent rain. The storm left the building roofless and the floor covered with “mud, blood, feces and glass,” according to the team.

Throughout the night, they cleaned up and used furniture for exam and operating tables with tarps as a makeshift roof. By 8 a.m., the clinic was open and receiving patients.

Those seeking care had deep, festering, infected wounds all over their bodies. The limb injuries were horrendous. It had now been two days since the storm hit and many people in the area had essentially no medical care up until the team’s arrival.

A Change in Plans

This team had planned on being in Mexico for a routine humanitarian medical mission, but instead found itself in almost unimaginable destruction in a remote part of the Pacific island nation.

The team is based in Mammoth Lakes, California, though they have team members from around the country. The had seven doctors and 11 other team members and would have provided elective medical and surgical services to an underserved area.

On the evening of Thursday, Nov. 7, the team had all of their medical equipment and supplies packed and ready for their Friday morning flight from Los Angeles to Mexico. Yet at around the same time, typhoon Haiyan was brutally cutting through the Visayas region of the Philippines as the strongest typhoon on record.

An urgent call came in to the Mammoth leadership: “Can you divert to the Philippines?” The request came from another humanitarian group, but one without doctors. They were aware of the emergent need in Visayas, and thought to partner with the Mammoth group. The MMM team met early Friday morning, had a vote, and changed their plans. Soon thereafter, they boarded a plane headed for Manila.

Dr. Sara May, an emergency physician with experiences from Los Angeles to rural Minnesota, was one of the Mammoth physicians on the Philippine mission and shared their amazing story. Other members of included doctors with specialties in orthopedics, thoracic surgery, anesthesiology and OB-GYN. Dr. Mike Karch, an orthopedic surgeon and MMM team leader, was present at Ground Zero and even teaches an annual course on mass casualty training. In essence, this was the right group, at the right place, at the right time.

“The wounds we saw were so extreme,” Dr. May recalled.

Many of the lacerations were to the bone, including those on the scalp. “We saw a lot of fractures,” she said, including “open” fractures where the bones protruded from the skin. Many were deeply infected and required surgical debridement in their makeshift operating room.

In many hurricanes, typhoons and tornados, injuries occur from flying debris. Dr. May estimated that 70 percent of the wounds they saw were caused by displaced corrugated tin roofs that had become flying guillotines. Many of the other injuries were from coconuts flying at 150-200 miles per hour, the estimated wind speed of the typhoon.

With their small makeshift clinic at the town hall, the patients kept coming. This in one of the areas where “disaster medicine” differs from the regular emergency care people would receive on any other day. On an average day in the ER, there is a big team to care for a few badly hurt patients. In a disaster, you have a small team to take care for many people with critical injuries all at the same time.

The anesthesiologists in the group had a limited amount of sedatives including ketamine and propofol, however it was not enough to provide anesthesia for all of the patients. The team needed to come up with another way to allow pain-free surgery, since they were seeing an average of 40 patients a day. A fortuitous last-minute equipment addition made this possible.

The company Fujifilm makes a small, portable ultrasound machine called the .
Apparently, a company representative had provided a loaner Sonosite to the team for the trip. It is about the size of a small laptop computer and can run off batteries, making it ideal for an environment without electricity.

In addition to looking for internal injuries and looking at unborn babies, this ultrasound device is also able to locate nerves within the body. The anesthesiologist could then inject a small amount of a numbing medication called lidocaine directly into a nerve. This is called a regional nerve block and can make an entire limb numb and free of pain during wound debridement or even surgery.

Most everyone seen during the first two days had moderate to severe wounds that were often infected. The team had oral antibiotics which they used to treat the infections after the wounds were surgically cleaned. Some injuries were so severe that amputations were necessary to save lives.

Taking Care of Themselves

Another challenge for the MMM members was keeping themselves healthy enough to continue caring for all of the incoming patients. One of the caveats of any rescue mission is to ensure your own health and safety, thus avoiding becoming another victim.

The team’s bottled water they carried with them ran out after the first day. There was a deep well nearby that they used on day two, but the surrounding area was littered with the dead, who were now starting to decompose, raising fears of well water contamination. They saw over 100 dead bodies in the area.

To have access to clean water, they set up a water catchment system created out of tarps that covered their clinic. The captured rain was then filtered and used by both MMM members and their patients.

Their food consisted of “meals ready to eat” or MREs. These are standard fare for field military operations and usually three of the 1200 calorie meals are eaten daily. The MMM team had enough MREs for about one per person per day, so each ate half of one in the morning and the other half at night.

Another source of calories that was particularly popular with their younger patients was a duffel bag of left-over Halloween candy that made the journey with them. This was used not only for the kids, but also for the desperately ill adults who needed some form of oral glucose to sustain them.

By day three and four of the mission, many of the patients they were seeing were coming back for rechecks and further debridement. Dr. May believes 90 percent of their patient interactions were “life-saving.”

The most seriously injured were able to be evacuated out of Tanauan by helicopter which came as a relief to the team. Some patients had severe sepsis, or bacterial blood poisoning, and others had severe wounds with at least one patient with necrotizing fasciitis, also called flesh eating bacteria. Another young woman, who had an emergency caesarian section done by the team, was also evacuated along with her healthy new baby.

As the team wrapped up their mission on Thursday, a four-person team from Japan with one surgeon came in and took over care in the region. The team from Japan, rested and loaded with fresh supplies, was able to continue caring for those injured who remained in the community.

New medical teams going into the areas of devastation, including the from Hawaii, will likely encounter debilitated patients with pneumonia and malnutrition as well as those with acute diarrhea from contaminated food and water. Patients with chronic medical conditions such as diabetes, high blood pressure and heart problems may also be suffering if unable to get their regular medications.

The Mammoth Medical Mission’s originally planned trip to Mexico has been rescheduled for May 2014.

Dr. James Ireland is an internist/nephrologist on Oahu and an Assistant Clinical Professor of Medicine at the John A. Burns School of Medicine. He is the former director of the Honolulu Emergency Services Department.