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“Many disciplines on an island”
7th National Allied Health Conference 2007
No discipline is an island
Allied Health participation in an Australian Medical Assistance Team in Java
- the pharmacist’s perspective
tion: Yogyakartapronounced “Jogjakarrrrta”
located in central Java
active volcano (Merapi) to nor
Borobudur to northwest
(Bhuddist holy place, World H
Bantul region (many small villa
and Indonesian sea to south
Dr Julie McMorrow
Critical Care PharmacistRoyal Perth Hospital
and
Health LogisticianAustralian Medical Assistance Team (WA)
Primary Care / Public Health Mission Yogyakarta, June 2006
Civilian medical assistance teams
� first deployed post-tsunami in 2004/05
� small teams, specialised but with broad experience
� multiple roles
� disaster response training
� exchange of information, goodwill
� other countries prefer civilians over troops
� Australian Defence Force not sent to Jogja
Australian Medical Assistance Teams (AMATs)
Team Alpha� May 31 - June 14
� acute surgical mission
� NSW/ACT hospital, CareFlight, Urban Search And Rescue personnel, AusAID and EMA liaison (total 27 members)
� “first team in” has the hardest job!
� 4-10 surgeries per day @ TNI field hospital in sports stadium
� worked with Ludeira + Bethesda Hospitals
� interrupted by volcano evacuation alert Thurs 8th June
� we “inherited” their cache (surgical equipment, drugs, supplies)
Australian Medical Assistance Teams (AMATs)
� Team Bravo (that was us!)� June 12-26
� first night/day: handover from Alpha Team, establishing relationships with local organisations
� primary care / rehabilitation / public health mission
� WA hospital, GP, public health and FESA personnel, AusAID and EMA liaison (total 14 members)
� first time Allied Health included (physio + pharmacist)
� handed over patients and cache before departure
AMAT-WA (Team Bravo)� Doctors:
Andy Robertson (State Health Disaster Management Coordinator; Team Leader)
Mark Little (ED/Tox/SOS retrieval), Helen Mead (ED/Paediatrician),Judith Findlay (GP/Red Cross), Charles Douglas (Public Health, Kalgoorlie)
� Nurses: Muriel Leclercq (ED/Remote Area/Disaster Management; Deputy Team Leader),
Angie Jackson (ED/midwife/SOS retrieval); Megan Scully (Public Health)
� Physiotherapist: Nick Buttigieg
� Logistics: Lloyd Bailey and Rik Lieftink (FESA logisticians)
� Health Logistics: Julie McMorrow (critical care pharmacist)
� Liaison: Katherine Mitchell (AusAID); Malcolm Purcell (EMA)
AMAT Bravo, Yogyakarta, June 2006
Logistics: what’s involved?� “the art of moving, housing, supplying and maintaining”
a team of people
� military, emergency services & health carelogistics combine in disaster preparedness and response
� “disaster cache” = supplies, equipment, drugs (and information!)
� pharmacist logistics experience
� “quantity surveying”, stock control, troubleshooting
� emergency medicine, intensive care, primary care, paediatrics
� infectious diseases / other public health issues
� Bali bombings, plane crashes, industrial explosions
� tsunami response & team support
FESA logistician roles: overview� planning, packing, transport & storage
� safety briefings, emergency equipment & evacuation
� assistance with medical equipment, drugs & supplies
� liaison and communication
� power and lighting
� village clinic setups
� cultural liaison, local meals
� lots more!
Health logistician roles � supplies, drugs, equipment (with Team assistance)
� planning, ordering, packing, transport, storage
� stock retrieval, issues, recording
� handover from Team Alpha medical logistician
� prior to departure and in Jogja
� drugs and vaccines; incl. “cold chain” and security issues
� bulk IV and irrigation fluids
� medical and surgical supplies and consumables
� medical and surgical equipment and power sources
� merging of cache: Alpha / other with Bravo
Health logistician roles � team personal care drugs, “crash packs”
� “refrigerate” and schedule 8 medications
� drug usage and safety information� paediatric drug dosing pocketbooks
� Therapeutic Guidelines: Antibiotic, Cardiovascular
� verbal advice, reminder tags on stock
� child safety reminders (secure village clinic drug storage)
� village clinic setups
� assistance with clinic dispensing
� clinical advice to health authorities � on request, via Team Leader and AusAID
� appropriate donation of unused cache items
Pre-departure timeline� June 1 (Thurs late): first notification
� deployed earlier to work on drugs/fluids/supplies lists
� June 2-5: at ED Pharmacists’ Seminar, Sydney
� first 8 vaccinations “on the way to the airport”
� obtained mobile no. for Team Alpha medical logistician
� ordered paediatric pocketbooks, antibiotic guidelines
� June 6-7: passport, consultation/drug lists/ordering,
liaison with AusAID re: Indonesian tetanus treatment
� June 8: packed cache (3.5 tonnes, 5-8 people)
� June 9: pre-departure briefing day; surgical team stood down
� June 10-11: team drugs, personal preparations, departure
Packing cache: DHL warehouse, Perth Airport 8th June
Pre-departure “incidentals”� AusAID “FYI” email cc’d Wed 7th June
� Indonesia requesting only IM tetanus immunoglobulin• IM (250 units per vial) for dirty wound prophylaxis only
� aware of need to anticipate actual tetanus cases• need 4000 units IV per case• 16 injections x 250 units IM into tetanic muscle very
painful, less effective
� advised AusAID (Red Cross Haematologist/CSL backup)• one case confirmed already (85yo male: fatal)• AusAID procured all surplus Australian IV TIG
� outcome• 105 x 4000 units IV sent urgently with AusAID escort• changed Indonesian tetanus treatment protocols
Pre-departure “incidentals”� Visa hassles Fri 9th June
� Team Leader / AusAID / EMA Liaison continued negotiations during briefing day
� Indonesian Consulate finally approved visas, but requested additional passport photos
• afternoon of Muslim Holy Day = little time • Monday = public holiday in Canberra
� logistics intervention: “phoned a friend”• Head of RPH Medical Illustrations Dept • had photographer sent to briefing• visas through just in time
Customs clearances� us? no problems - arrived Mon 12th June pm
� our airfreighted supplies? - delayed until Wed am
� what about the “refrigerate” drugs?
� cold packed by RPH Pharmacy Store Fri 9th June
� knew “good for 3 days” BUT had planned for delays:
had “out of fridge” stability data with me
� all items OK >> 48hours: NO WORRIES !
� time-consuming/impractical to replace stock
� “prophylaxis of angst” = important pharmacist role
Yogyakarta (pronounced “Jogjakarrrrta”)
� official language Bahasa Indonesia � villagers / older people: Javanese dialects, even Dutch
� “polite” words in Bahasa and Javanese: enough to get by
� with patients, useful to know:• body parts• “pain”, “diarrhoea”, “infection” words• “are you sleeping OK?”• “time” and “quantity” words
� medicine directions written opposite way to ours (“ 3 / ½”)
� our interpreters were fantastic !
Yogyakarta Earthquake
� Sat 27th May 2006
@ 0554am
� epicentre in Bantul region,
south of Yogyakarta
� preceded by eruption of
Mt Merapi since 8th May
� serious eruptions every 10-15 years
� extremely catastrophic eruption in 1006 !
2006 earthquake
� at least 5800 dead
2006 earthquake� over 30,000 injured
� typical story - “house shook for 30 seconds, then fell on me”
� worsening of pre-earthquake injuries:
people with broken legs and hips had to run away
� all wounds had to be considered tetanus-prone
� up to 600,000 homes destroyed / uninhabitable
� mainly in Bantul, Klaten, Jogja districts
� 80-100% of homes destroyed in many villages
� approx 30% severely damaged in Jogja city area
� over 1.5 million people homeless?
Hospitals overwhelmed� Sardjito Hospital = the “Royal Perth” of Jogja
� normally 750 beds
� 3300 patients late May
� 450 earthquake inpatients late June (4 weeks)
� most outside on footpaths during first week
� overcrowding, fear of aftershocks
� many discharged with “follow-up in 3 months”
� found in villages by Team Bravo
� some unable to walk
� families not sure what to do
Hospitals overwhelmed� 10-bed ICU at Sardjito, but:
� 50 patients with severe sepsis @ 14th June
� resistant Pseudomonas, Klebsiella
� lack of suitable IV antibiotics
� “100 patients needing albumin”
� Medical Director requested assistance via AusAID
? how would we cope in a similar situation ?
Assistance provided to Sardjito� antimicrobial therapy advice to Medical Director
� based on experience post Bali bombings (RPH 2002-2003)
� likely “bugs” involved and susceptibilities (later confirmed)
� antimicrobial agent selection
� dosing guidelines (with adjustments for renal dysfunction)
� literature references (via internet/faxed from RPH)
� RPH infectious Diseases backup
� my copy of Sanford! (antimicrobial therapy pocketbook)
� urgent airfreight arranged by AusAID� meropenem injection
� albumin 25% (for selected patients only!)
“Non-mission” assistance� primary care / public health mission,
BUT hospitals overwhelmed, requesting assistance
� in future, if requested, a small “hospital team”
(eg: ID Physician, Intensivist, Clinical Pharmacist)
could provide strategic support to local Specialists
� Team Leader “triages” requests
� considers clinical, political, practical and cost issues
� refers to appropriate agencies / team members
Post-earthquake problems� food shortages
� people: first 2-3 weeks � domestic animals and birds
� water supply� contamination� drops in well levels (as much as 90 metres!)� broken or melted water pipes (volcanic ash)
� accidents� rebuilding, falling debris� compromised living conditions, eg: burns & scalds
village water supplies disruptedby earthquake,significantdrop in well water levels
Post-earthquake problems� tetanus
� low vaccination rates (20% overall?)
� injuries during earthquake
� altered living conditions
� rebuilding accidents
� 73 reported cases by late June
� 38% case-fatality rate
Post-earthquake problems� other infectious diseases
� diarrhoea
� measles
� typhoid
� scabies
� respiratory tract
infections
� avian influenza
education & vigilance
possible volcanic eruption danger areas
Team Alpha
transported cache
to and from
TNI field hospital
in sports stadium
each day
Team Bravo: post-arrival briefing Mon 12th June
AMAT Alpha cache handover in Jogja
Muhammadiyah Tues 13th July
Assembling team “crash packs”
Merapi’s moods: changes over 5 minutes
“Room 552 cache”� drugs needing extra security
� medical equipment (if to be kept charged)
� “refrigerate” and “store cool” drugs
� freezer bricks x 60! � rotated through different parts of fridge/freezer
� thermostat kept at 5�C� maintained actual room temp at 18�C
� helped keep fridge temperatures @ 2-8�C
� slept in a jumper
benzodiazepinesstorage
Cache drugs sorted by therapeutic category for ease of retrieval
Picking stock for clinics
Morning logistics briefing
Local health centre:
“moderately affected”
village, Bantul
Setting up a village clinic
� Organise stock in advance
� Meet with officials to identify potential site
� Meet with Head Man of village, landowner
� Clear site
� Set up tent and stock
� Advertise (“gratis” was usually sufficient!)
� See patients
Local medicines packaging & labelling� bulk oral medicines in large bottles
� usual pack size = 500 tablets• cheaper, but contamination / mixup / overdose hazards
� English, American or Latin drug names• some familiar• some unfamiliar
to Australian doctors and nurses
� some “problem” strengths or ingedients• dextromethorphan 15mg
(Australian products = 5mg per dose) • paracetamol with caffeine
Local medicines packaging & labelling
� patient “take-home” medicines
� small quantities, eg: 1-2 days of an analgesic
� zip-lock plastic bags
• no dispensing label
• not everyone could read
• brief directions written onto plastic in ballpoint pen
• eg: “ 3 / ½” (take HALF a tablet three times daily)
• we used indelible felt-tip pen (easier to read)
Clinic safety � considerations:
� local people are small, not used to effects of medicines• use lower doses• short courses, then review
� establish safe dispensing, checking and recordkeeping systems
� ensure treatment is sustainable / able to be monitored adequately
� identify items/procedures for use by AMAT only
� identify any items not to be left overnight in clinics
� keep all medicines, disinfectants, etc. out of reach of children; warn village elders to keep children away
� avoid drinking cordial in front of children
� safe disposal of sharps, medical waste, unwanted medicines
before we introducedsharpscontainers!
Prevention of “disaster under plaster”
Stress management and education- by psychologists, midwives and public health stafffrom combined AMAT-WA, SOS and Muhammadiyah teams
� sleep disorders
� art therapy for children
� women’s clinics
� infant feeding
� immunisation
� diarrhoea prevention
� contraception
� sexually-transmitted infections
� avian influenza awareness
Evening reports: clinic teams, rehab, public health
Team room:reports,meetings,emails home!
What Team Bravo did…� set up 7 village clinics in Bantul and Klaten
� saw nearly 1800 patients (10 full + 2 half days)
� arranged patient follow-up
� evacuated patients needing hospitalisation
� provided rehab reviews, mobility aids
� immunised 730 people (mainly tetanus, also measles)
� provided village education sessions,
using local health care workers (very entertaining!)
What Team Bravo did…� worked with Indonesian SOS and Muhammadiyah
doctors, nurse midwives, nurse paramedics, physios,
psychologists, pharmacists, others
� provided critical drugs and information to Sardjito Hospital
� donated and delivered remaining cache before departure:
equipment, unused drugs, IV fluids and supplies
� provided copies of treatment records to patients,
local and government health offices, WHO
� handed over patients and clinics to SOS / Muhammadiyah
Allocation and packing of
unused cache
for pre-departure
donation
to Sardjito and
Muhammadiyah’s hospitals;
vaccines went to
Provincial Health Office
home:
“did all thatreally happen…
…or did we just
dream it all?
Things for next time: cache� In Perth: pack by therapeutic categories
� Compile a “disaster formulary”
� rationale for inclusion of each item in cache
� possible substitutes if stock not available
� supporting info / precautions for drugs + supplies
� Treat consumables + equipment like drugs
� use generic as well as common names (what’s a “diagnostic set”?)
� no-one “rearranges” the stock except logistics staff!
� record quantities issued manually, update at night if possible
Things for next time: record-keeping� Pre-printed picking lists with blank columns
� suitable for “pen & paper” use if no computer access
� daily orders versus daily issues
� notes and adjustments
� provision for additions: new items, other caches
� easy generation of “donations lists”
� stock levels: at start, daily balances, at finish
� bring hard copies (1 per day) in case no printer / copier
� Laptop� bring own (1 per logistician?)
� internet access / email useful if available
Things for next time: “cold chain” considerations� Fridge / freezer
� supplying our own next time?
� include cooler bricks (approx 40?)
� temperature monitors for different areas
� Smaller portable coolers (“Eskies”)
� 2 per treatment team: for clinic + “walkabouts”
� temperature monitoring themometer for each
� fewer cooler bricks needed if smaller• less dead space • less weight (occupational safety issue)
In conclusion…� Inclusion of a pharmacist as health logistician
� assisted FESA logistics staff, who were less familiar with health
terminology and equipment
� freed doctors and nurses to spend more time with patients
� prevented unnecessary reordering of “refrigerate” products
� Increased familiarity with surgical supplies and equipment,
Indonesian product knowledge and prescribing practices will be of
benefit in future deployments
� Working with a multidisciplinary team to assist the people of
Java was challenging, but very rewarding
AMAT-WA thanks…� our translators:
� Ririn, Fitri, Widi, Deborah, Bastian, Anton
� Nathan and the gang from HK Shipping
� drivers, security guards, local work crews
� hotel staff
� local officials: Muhammadiyah, village elders
� landowners, villagers who cleared clinic sites
�everyone at home !
Our hard-working and multi-talented Translators: Fitri, Deborah, Bastian, Anton, Ririn and Widi
Disaster Preparedness and Management Unit Staffwho looked after us whilst we were away...
Photography: M Bundhowi (“Bun”)
AMAT Team members