doi: 10.1111/j.1742-6723.2006.00829.x Emergency Medicine Australasia (2006) 18, 199–202

© 2006 The AuthorsJournal compilation © 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Blackwell Publishing AsiaMelbourne, AustraliaEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty Ltd2006182199202MiscellaneousExperience from Nias earthquakeA Jackson and M Little

Correspondence: Dr Mark Little, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia. Email: mark.little@health.wa.gov.au

Angela Jackson, RN, RM, B Health Sc, Dip Health Sc, Crit Care Cert, MPH&TM, LLB, Clinical Nurse; Mark Little, MB BS, FACEM, MPH&TM,DTM&H, Emergency Physician and Clinical Toxicologist, Clinical Senior Lecturer.

PERSPECTIVE

On the ground in Nias in response to an earthquake – an emergency team’s experienceAngela Jackson1 and Mark Little2,3

1Department of Emergency Medicine, Royal Perth Hospital, Perth, 2Sir Charles Gairdner Hospital, Nedlands, and 3University of Western Australia, Perth, Western Australia, Australia

Abstract

Within a few short months of the tsunami, an earthquake measuring 8.7 on the Richterscale devastated the Indonesian island of Nias. The present paper describes the experi-ences of two emergency medicine staff deployed to the island operating in small teams onthe remote western part of the island. It discusses the benefits of utilizing experiencedemergency medicine staff and looks at lessons learnt from the deployment.

Key words: disaster response, earthquake, Nias.

Introduction

Nias, an island approximately 130 km west of Sumatraand straddling the equator, is approximately 5600 km2

in size and has a population approaching 500 000. On28 March 2005, Nias was devastated by an earthquakemeasuring 8.7 on the Richter scale. Early reportsclaimed there were thousands injured and killed withup to 30% of villages having been destroyed.

The present paper describes the experience ofemergency medicine staff deployed to this disaster andexamines the lessons learnt.

Team structure

Because of the presence of a large number of aid agen-cies involved in the ongoing relief efforts in Banda Acehafter the tsunami, there was a significant mobilization

of numerous personnel and equipment to Nias. Thiswas hampered by the remote location of the island –everything needed to arrive by boat or air, and with adamaged airfield and poor weather, access initially wasdifficult.

Interplast, a voluntary arm of the Royal AustralasianCollege of Surgeons, had been working with Interna-tional SOS in rotating Australian medical staff tothe hospital in Banda Aceh. Immediately after theearthquake, AusAID, the Australian Government aidagency, contacted and funded Interplast and Interna-tional SOS to move staff and medical equipment to Niasand link up with Surfaid, a non-government organiza-tion. As a result, three Australian personnel from BandaAceh – a general surgeon, public health physician andwound care nurse – flew to Nias 36 h after the earth-quake. They were joined by Indonesian medical stafffrom Surfaid and International SOS, and an emergencyphysician and emergency clinical nurse from Perth (the

A Jackson and M Little

200 © 2006 The AuthorsJournal compilation © 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

authors), both with public health and overseas aid expe-rience. Four Australian engineers from RedR weredeployed with the medical team.

Mission aim

The team’s mission was to provide emergency medicaltreatment and evacuation to earthquake victims,perform a needs assessment of villages and villagers,identify any disease outbreaks, perform structuralassessments of public buildings and bridges, and reportwhat aid was being received in the area of operation.As most of the aid organizations were based around thecapital, Gunung Sitoli, on the east of the island, the teammoved to the bay of Sirombu on the west of the island,and was given responsibility for the entire west coastand central mountainous region.

Assets available

Surfaid is an organization that has close contacts withthe surfing community, and had been regularly per-forming primary care clinics in the Nias area. Some ofthe staff lived in Nias. As a result, Surfaid had manylocal contacts and was able to mobilize at least five surfcharter boats that would be used by the teams as a baseand for moving up and down the west coast. Otherboats were chartered to logistically support the teamsas well as supplying essential aid such as food, oil andshelter for the people of Nias. Collocated with the teamwas a Squirrel helicopter, funded by NZ Aid, a RIB(rubber inflatable boat that could carry 8 and travel at30 knots), motorbikes and numerous runabouts. Allwere under direct tasking control of the team.

Command and control

It was realized early that a simple command structurewas necessary. An International SOS logistician wasbased at Gunung Sitoli, and became the liaison pointbetween the team and the United Nations, World HealthOrganization and all other agencies. Within the team,one of us (ML) was placed in charge of the operation,with an Australian non-medical Surfaid member beingplaced in charge of ops/logistics. The two team leaderswould meet at the end of the day, debrief teams andplan with the logistician at Gunung Sitoli. All membersof the team would meet after dinner to discuss the day,

reviewing what went well and what did not, and planthe following day. Written reports were sent out eachnight and this information regularly appeared in UnitedNations and World Health Organization briefingdocuments.

Daily operations

Teams of three to five persons would leave early eachmorning. The teams consisted of both Australian andIndonesian health personnel, a translator (people on theisland speak Nias not Bahasa) and an engineer. Usingeither boats, the RIB, helicopter, or travelling on theback of motorbikes, the teams would travel to pre-identified areas and commence their assessments.Often, if inserted by helicopter, teams would walk alongvillage tracks with backpacks of medical equipment.This made the teams very mobile.

Often the teams would be the first aid to reach thesevillages. People would great us sobbing and hug teammembers. In discussion with the village chief, injuredpeople were identified and treated. Those that neededsurgical intervention were identified and arrangementsmade to transfer these to USNS Mercy hospital ship.Needs assessment, including a specific focus for diseaseoutbreak, was performed using structured question-naires. Food stocks, water supplies and structures wereexamined. Teams would usually return back to base bysundown, but on at least two occasions teams remainedin the field overnight.

Although the focus of the team was health, othermembers of the team not in the field became involvedwith food distribution. With Surfaid’s local knowledgeand contacts, we were able to unload and distributeapproximately 200 tonnes of food and other essentialsto remote communities on the west coast and surround-ing islands.

What we found

Throughout Nias, approximately 30% of all structureswere damaged or destroyed. There was no power, andwater supplies were often contaminated or destroyed.Throughout our stay there were frequent aftershocks,sometimes every 3–4 h, with the largest being 6.7 on theRichter scale. All the villagers were terrified of furtherearthquakes and were sleeping outside their homes atnight. Fortunately the teams did not detect any signifi-cant disease outbreaks.

Experience from Nias earthquake

© 2006 The Authors 201Journal compilation © 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

In the first few days the teams were confronted in themajor centres with dozens of patients suffering mainlyfrom fractures, infected wounds and crush injuries. Asthe days went on the number of casualties declined.However, even more than 2 weeks after the earthquake,teams were finding patients in villages with significantorthopaedic injuries and wound infections. In all, over1500 patients were treated and 50 patients were trans-ferred by air for surgical management.

Benefits in deploying experienced emergency medicine staff

We believe that there were many benefits in havingemergency medicine staff operating in the Nias earth-quake. The public hospital system was supportiveof the request for staff and as such we were able torapidly deploy to Nias. We are used to working inchaotic environments, working in teams and dealingwith many different agencies. Clinically, we were ableto rapidly triage, assess and manage patients and wewere regularly used by other team members as aresource for advice on managing injured patients.Because of our experience in retrieval medicine, wewere able to effectively determine who should be evac-uated by air (or more importantly, who should not). Wefound it extremely beneficial to have had public healthtraining. We were also fortunate to have senior nurses,who were able to work independently and lead individ-ual teams.

Lessons learnt

There were many valuable lessons learnt.

Before planning

It is important to adequately brief teams prior to deploy-ment. Issues that need to be covered include:• Latest available intelligence on the unfolding

disaster• What to take (both personal and professional)• Concept of operation• The aims of the mission• Command and control• Accurate and detailed maps• Medical evacuation plan for both patients and team

members• Money

• Reporting requirements• Uniform/identifier equipment• Safety issues• Exit strategy.

Rapid assessment team

In an attempt to obtain an accurate picture of thedeveloping disaster and to commence planning forthe arrival of the emergency team, we believe thatthere needs to be a rapid deployment of a ‘rapidassessment team’. This team could consist of medical,logistics and communication experts who rapidlyassess the disaster and recommend team aims andrequirements.

Communications

Communications were difficult from the west coast ofNias, even with the use of satellite phones. We had nomeans of communication between the teams whenthey were in the field. At the base, effective communi-cation was via very high frequency hand-held radiosbut this had a limited range. Often messages were sentto and from Gunung Sitoli using a motorbike dispatchrider. For future missions effective communicationsystems that are portable, simple to use and robust arerequired for all teams.

Use of boats

Teams were based on charter boats anchored approxi-mately 0.5 km off the coast. This excellent resourceprovided transport, shelter, safety, communications(email and satellite phone), a planning and team meet-ing area and a means to adequately feed and rest theteams.

Use of resources

We believe that the overall success of the mission wasachieved by having small mobile teams and assets thatwere collocated and under our direct tasking control.We would strongly advocate any team have direct con-trol over such assets. Being based in a remote area, thepresence of a dedicated helicopter enabled rapid move-ment of teams and was invaluable as a safety asset.This was demonstrated when one of our nurses sus-tained a head injury after falling off a motorbike in themountains, and we were able to rapidly move her to theUSNS Mercy for assessment.

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202 © 2006 The AuthorsJournal compilation © 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Cooperation with local agencies

We found that by meeting and cooperating with thelocal leaders and organizations we were able to effec-tively operate in the region and were able to hand onroles and responsibilities when we left the disaster zone.

Next time

It is highly likely that Australian medical teams in thefuture might need to respond to disasters, either manmade or natural, in our region. Emergency medicinestaff have many skills and abilities that are ideallysuited to respond to such disasters. Planning, either ata college level or at a state/federal health level, needsto occur so that plans are developed and teams andequipment are identified and are ready to respond toany future disaster.

Conclusion

By the time the team left Nias on 18 April, 3 weeks afterthe earthquake, the children had returned to school,

power was restored around the capital, the marketswere operating and food aid was getting to the remotevillages. The airport departure lounge, which was beingused as a patient treatment facility when we arrived,was now functioning as a departure lounge (completewith a souvenir selling shop!).

All members of the team felt that although we wereconfronted with significant problems we had made adifference to many of the people of Nias. We all foundthis to be a rewarding experience both professionallyand personally. However, for the island of Nias, manylong-term problems remain.

Competing interests

None declared.

Accepted 10 November 2005