When Nothing Is Left: Disaster Nursing After the Tsunami

Peggy W. Dryden, RN, MSN, MBA, MLS

Disclosures

March 28, 2005

Editor's Note
Only a few months have passed since the Indonesian tsunami disaster occurred on December 26, 2004. The town of Banda Aceh , Indonesia, was reported to be one of the hardest hit areas. This month, 2 nurses, with little preparation time, answered the call to help in the disaster relief effort in Banda Aceh. Jeanie Schmidt, RN, BS, and Carrie Randle, RN, BS, who met while in Banda Aceh, share their experiences as volunteers working with the International Medical Corps (IMC).

Jeanie Schmidt, RN, BS.

Carrie Randle, RN, BS.

Question: Could you describe how you made the decision to go to the disaster area?

Jeanie: I made my decision to go to the disaster area as I watched the video footage on CNN. I felt chills while watching the report, it touched me so deeply. The decision to help in the relief effort felt like a calling. I was compelled by an overwhelming desire to be there. While listening to the reports on CNN, I recall an Indonesian man from the area grabbing the microphone from the reporter and asking, "America, where are you?" It was so moving that I was brought to tears. So, I copied down the names of the relief organizations, the names of the reporters, and their locations. I sent emails to anyone I could find associated with the disaster relief.

In the process, I found the International Medical Corps (IMC) Web site, and I was so impressed with their work. IMC, a nongovernmental organization (NGO), is a nonpolitical and nonsectarian organization that provides emergency healthcare and works to rebuild the capacity of the health services.

I applied online with IMC and called them to follow up. Within the week, I had been accepted and was given 48 hours notice for departure. I became part of an emergency deployment that was a direct result of Colin Powell's visit to Jakarta to assess the needs of the disaster area.

I was especially pleased to be chosen to go to Banda Aceh, Indonesia (located on the tip of the island of Sumatra), because it was the hardest hit area -- the "ground zero" of the earthquake and tsunami. Banda Aceh is very isolated, and providing assistance is a challenge because the country has been closed to outsiders since 1976.

Carrie: I was horrified when I first heard about the earthquake and the tsunami. My heart broke as I began to see the video images from the disaster area. I felt a strong need to be there, and I knew I had skills that could be of use. I was open to going to any of the areas affected. Initially, I was most interested in going to India. However, as I began talking with IMC, whose team was going to Banda Aceh, I decided that this was an organization that was prepared to really make a unique and significant contribution. As I began to learn more about the affected areas, I learned that this area was the hardest hit. I wanted to be there.

After I called IMC, I received a call back within 2 days. Forty-eight hours later, I was on a plane headed to Indonesia. From Los Angeles, we flew via Taipei and Kuala Lumpur to Jakarta, where IMC has their regional office. An advance team left Jakarta immediately. A day later, we traveled by plane directly to Banda Aceh's main airport.

Aceh province is on the northern tip of Sumatra. This area has been closed to the rest of the world for about 30 years because of military conflict in the region. The army in Aceh has been fighting the Indonesian army for independence for years. The Aceh area governs with a modified Islamic law. The people are extremely religious and devout. All women keep their heads covered; most men wear the traditional skull cap.

Question: What was the trip to Banda Aceh like?

Jeanie: It was an amazing effort by IMC to get the group of 25 nurses and doctors by plane to Jakarta. We spent a couple days in Jakarta getting briefed, organizing and cataloging medical supplies, and completing personal health requirements. We also had layovers in Taipei and Kuala Lumpur on the 35-hour trip to Banda Aceh.

Question: What did you see when you arrived?

Carrie: My first impression of Banda Aceh was that most of the cars on the road displayed a sticker or placard indicating that they all belonged to an NGO. There were so many NGOs already in the area; I wondered at first what we would do there.

On the trip from the airport, I saw many flattened buildings. Half of the homes appeared to be rubble. It seemed that there was great disparity in the living conditions prior to the tsunami. For instance, I saw ornate and very large homes next door to small shacks. As we came closer to the coast, I began to see the tents and the many people living there. I saw makeshift cities often located within or near a mosque. Also, we could see the large mass burial grounds from the road. Some of the roads were covered in rubble and mud, while others had been cleared for cars to travel. Everywhere mud, debris, and rubble covered the ground. People were picking through the debris in the midst of the rubble and salvaging whatever they could -- wooden beams, tin roofing, muddy mattresses, pots, pans, anything.

Carrie Randle, RN, BS, in Banda Aceh.

Question: What were your daily activities like?

Jeanie: Not surprisingly, the day-to-day activities varied. The only thing you could count on was that there was nothing you could count on. Hour by hour, we had to roll with all the changes despite best laid plans and preparation. IMC was not kidding when they included "lots of patience" on the "what to bring" list.

Each day, I woke up around 3:30 am in order to be able to shower ahead of the 20 residents in the house. Generally, personal hygiene was a challenge. The only sink available was in the kitchen. So, after using the bathroom, we used the personal hand sanitizer we brought to clean our hands.

We were fortunate that the toilets in our house had seats. For the most part in Indonesia, the toilets were all "squatters"; that is, a hole in the floor. Toilet paper was something you wanted to keep on your person as paper products were scarce. The bathroom floor was always wet and dirty, as water from the "open" shower flowed across the room to the 1 floor drain near the toilet. The general rule in the house was that shoes were to be left outside the house. So, a trip to the bathroom in bare feet was unpleasant at best.

Showering was a way of feeling comfortable. At night, sleeping was difficult in the heat because of the constant sweating. I joked that I was on "bid" or twice daily showers. Even that was not sufficient.

During my first assignment, I worked with another nurse in what was left after the mud was shoveled out of the Central Banda Aceh University hospital emergency room (ER), and the Zainal Abidin Hospital. Procedurally, to begin working in an area, each person had to affiliate with someone who already had something set up, such as a hospital ER, for example. You then had to attend the affiliate's meetings as well as return for 3 consecutive days before you could start working. The shifts were 7-10 hours on average. It was great but challenging to work with physicians and nurses speaking different languages. Each group brought in their own medicines (I noted medications from 6 different countries) and supplies to the ER.

An area just outside the Central Banda Aceh University Hospital Emergency Room.

A portion of the Central Banda Aceh University Hospital.

We had groups in the ER from Switzerland, China, Korea, Indonesia, Belgium, and Spain, not to mention the Australian and German Armies who were also there working to get the water and sewer functioning. Each group was setting up their own operating rooms, laboratories, and radiology facilities on the grounds. The innovative Singaporeans took it upon themselves to shovel out their own pod and create a hospital unit for the ER to admit to.

Carrie: I was awakened each morning (about 5:15 am) by the call to prayer over the Mosque loudspeakers. You could hear other prayers being sung in the distance. The morning air echoed with these prayer songs.

My shift began each day at 8:00 in the morning. There was no such thing as a typical day. I assisted physicians from IMC, Spain, Switzerland, China, and even Afghanistan in seeing patients. I was treating patients in respiratory distress with almost no respiratory medications available, monitoring laboring women, cleaning and dressing wounds, searching for medications, and trying to figure out what the medication I was looking for was called in Spanish, Greek, Indonesian, or Chinese! I was assisting Indonesian volunteers in triage, monitoring patient flow, searching for beds or field hospitals that could take more acute patients, transferring patients by stretcher to various places, begging field hospitals for an x-ray, or maybe a lab test, starting IVs, making bedpans, urinals, sharps containers, cups, emesis basins, and anything else from empty water bottles, searching for water, searching for a mop, cleaning the floor, attempting to sterilize equipment, and finding a place for incoming "ambulances" either on a cot or sometimes the floor. It was chaotic, but as in any ER, in the middle of the chaos there was some kind of order being established.

IMC volunteer nurse Carrie Randle examines a child in Banda Aceh. Photo: International Medical Corps/Tim Smith.

Carrie Randle treating a patient's wounds in the ER with local staff translator, Wanda.

Volunteer nurse Jeanie Schmidt with IMC cares for patients in the recovery room of a field hospital in Aceh, Indonesia. Photo: International Medical Corps/Tim Smith.

Question: Where were you and your team housed?

Carrie: Much to our relief, the IMC had acquired a home for us to live in. We had anticipated camping in the mud for 4 weeks. Our team of 25 was spread all over the house. There were cots set up in the hallway and on the patios; bedrooms contained 5 people in beds and cots. Clothes lines were hung from every possible angle with mosquito nets hanging from them. We were lucky as we had running water and electricity (most of the time). Breakfast and dinner were prepared by local people who had been hired by IMC to cook for us. We had fried eggs and rice for breakfast every morning and some sort of fish and rice every night for supper. It was nice not to have to worry about cooking so we could concentrate on our work. (The only thing missing was a cold diet soda.)

Jeanie: Living arrangements turned out to be far better than the tent camping we had expected to have to do. In general, the heat and humidity are stifling in Banda Aceh, though. There are no screens on the windows. There was little air movement and no air conditioning or fans. The flies were especially rampant with all the dead bodies exposed for days, and the mosquitoes were vicious and relentless. We kept mosquito repellent with DEET on every area of exposed skin, reapplying it frequently, and we still received multiple bites. Sleeping under a net treated with Permethrin was a sure way to wake up to many mosquitoes hanging in wait on your net, even inside the house.

Question: Would you describe the people that you met during your stay in Banda Aceh?

Jeanie: The Aceheans are a lovely, kind, appreciative, and wonderful people. IMC hired local Aceheans who worked as drivers, translators, and house hands. We became especially close to the 2 young women who cooked for us, Jud and Ayus. The women spent hours daily prepping what few vegetables and spices they found to cook with.

When we arrived, both Jud and Ayus were sick from aspirating fluid in their lungs and both nearly died during the tsunami. A team physician, Dave Stockton, treated them at the house. Ayus had tragically lost her sister in the tsunami and Jud lost both her husband and baby during a family outing to the beach. Even though we could barely communicate, the pain of their loss was clear. Jud would say, "my baby" as she held and rocked an imaginary bundle in her arms. She would ask me about my husband and tell me again how the wave had taken hers. It broke my heart, and we all cried together. Ayus's family kindly adopted Jud as a sister when Jud lost her home and family. This practice of adoption was common in every Acehean family. All the Acehean people we met lost someone, if not their entire family and all that they owned. It was not uncommon for families to have lost 12 or more family members, as was the case with 1 of our drivers and a young boy working at our house.

Interestingly, on the plane home, I met another wonderful person, a native Sri Lankan man who was returning to the United States after bringing $2700 raised by his US Masonic Lodge to start an orphanage in Sri Lanka. It has been such a blessing to be near so many caring people.

Carrie: I found the people to be happy, warm, and friendly. Many times I was spontaneously embraced by people I came in contact with. An interpreter I worked with now calls me her "sister." The local people were curious about where we came from and why we were there. Many asked that pictures be taken with their "American friends."

Question: What was your most rewarding or demanding experience?

Carrie: The most rewarding experiences for me were the relationships I made with the local people in Banda Aceh and with the multinational staff. I have never worked with such brilliant minds and compassionate souls. I learned so much about things such as performing physical examinations, formulating differential diagnoses without the luxury of diagnostic testing, and creating a treatment plan that is effective with minimal resources. I learned to "go with the flow" and "roll with the punches." Every one of the local people we treated and worked with had lost so much: their home, their family, their friends, their business, their employment. I learned how to be strong in the face of unbelievable loss and adversity, how to keep going when the world you know is gone forever, and how to find hope and happiness when you have nothing left. I remembered what inspired me to become a nurse and why I love being a nurse. I love the ability to be at a person's side in their greatest hour of need and the intimate interaction and care that only nurses really get to provide.

Jeanie: The entire experience was so immeasurably rewarding that it would be impossible to single out one event as the best. Every smile or hug received from each and every one of the Acehean people was the best reward.

Working under the conditions and the chaos after a disaster, I would say the most demanding experience was being a part of the experience itself. Observing devastation and suffering on a mass scale and trying to function to the best of your abilities with limited resources is a unique, demanding experience. No trauma unit experience, ICU, or field experience can prepare you for a situation like this.

Question: What advice would you give a nurse considering doing something like this?

Carrie: For nurses looking to have a similar experience, I would say flexibility and creativity are 2 of the most essential skills required. It is important to keep an open mind and to leave the policies and procedures at home. I think in some ways it was actually to my benefit that I am a relatively new nurse and am still open to learning all I can. Basically, if you are an obstetrics nurse, you may never deliver a baby, but you can certainly assess a patient's hydration or respiratory status. If you are a PACU nurse, you may never be able to provide pain management (we had only acetaminophen for the most part), but you can provide comfort measures and emotional support. It truly is back to the basics of nursing.

Question: What resources would you suggest for our readers who want to learn more?

Jeanie: I would advise people to read about IMC and consider applying at http://www.imcworldwide.org . I would also suggest emailing any disaster relief site you can find. (Only IMC responded to my emails.) Readers can also contact their local hospital and religious organizations. Also, many organizations in the United States need help at home packaging and sending supplies and donations.

IMC is setting up a program to assist the surviving Banda Aceh medical and nursing students. Many suffered losses of family, homes, community, school, and potentially their careers. There are about 75 medical students in their final year who cannot afford to go back to school despite the fact that their tuition can be waived. Many have lost their homes and families, and they simply don't have the small amount of living expense money required -- about $1000 a year. My husband and I are adopting at least 1 student to help them graduate. There are not enough surviving nurses and doctors currently to staff the area. (For more information, go to http://www.imcworldwide.org/indonesianmedicalstudents.shtml .)

Carrie: There are many organizations that provide relief services not only internationally but locally. The American Red Cross is always looking for disaster relief team members and nurses (I worked with them in NYC after 9/11), and you might also consider International Medical Corps, Doctors Without Borders, and USAID.

About our interviewees: Carrie Randall, RN, BS, studied health promotion at Brigham Young University, Provo, Utah. After graduation, she worked in corporate health with Citigroup. After September 11, 2001, while employed as the Manager of Health Promotion for Citigroup in New York City, Carrie provided emergency mental health services to employees as well as assisted in disaster relief operations at Ground Zero with the local Red Cross. These experiences led to a pursuit in the nursing profession. Having moved to San Diego, she became a registered nurse in 2004, and was employed in an Emergency Department. She is currently pursuing a master's degree in a Family Nurse Practitioner program. Carrie can be emailed at carerandle@yahoo.com .

Jeanie Schmidt, RN, BSN, graduated with a degree in nursing from Rush University in Chicago, Illinois. She was employed as a critical care RN for 16 years in various settings including the ER, ICU, and most recently in the PACU and Lithotripsy unit at a division of Kaiser Permanente. Jeanie also received a BS in Biology in 2003. She is currently preparing to attend medical school. Jeanie can be reached at onyxs@earthlink.net .

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