„On 26 December 2004, an earthquake in the Indian Ocean, with its epicentre to the west of northern most tip of the island of Sumatra, generated the most human devastating tsunami ever reported in history of mankind. More than 300,000 victims were reported either dead or missing in Indonesia (253,958), Sri Lanka (40,220), India (16,399) and Thailand (8,600)₁.

The scope of the disaster in human terms is so great that there are no words to express it.” – as published by Garner.₁

The first mission of our team was realized two weeks after the tsunami. Besides establishment of a tent hospital and emergency medical care of the injured people, our primary duty was to provide the elementary health care of people living in the area. The system that we established was left for further caritative organizations.

Arriving to Sumatra from Jakarta our team was instructed to cooperate with the Portuguese medical team who had some difficulties. We encountered the problem in the scene that members and equipments of the Portuguese medical team were not or only partially allowed to enter the country due to Portuguese Indonesian political conflict. As a result of this, they were not able to build their tent hospital with an operating- and a postoperative room, and the site of the hospital was not properly chosen either.

Owing to the tropical rain and monsoon, the soil was watery and marshy making necessary to plan and build a basic drainage system. At the same time we were forced by permanent hot weather to protect our tents from the excessive warm. The best way seemed to be to circulate the air or to use air-condition.

The most important and determinant criteria for choosing the proper site of the tent hospital proved to be as follows: the proper distance from the disaster area, the accessibility, and being of the hospital defended from a new tsunami.

Our medical team was divided into three smaller teams and worked in disused surgeries. Patients required hospitalization were transported to the tent hospital by hired ambulances under medical supervision (guarded transport) for further check-up, surgical intervention and/or for observation. These smaller teams consisted of one internal/emergency specialist, one surgeon and a nurse. The hospital staff included an anaesthesiologist, a surgeon and a nurse. This composition proved to be optimal for a three-member small team.

For surgical intervention we had to ensure the necessary equipments and staff of anaesthesia, to develop an operating theatre and postoperative room, respectively. Separate places would be needed for patients with infections to be isolated, this, however, usually cannot be provided in these circumstances. A further important aspect to be considered that each patient has to be transported to the proper place where adequate treatment can be provided. To meet this expectation is usually difficult, because most of the people exist in very crowded refugee camps where 200-500 refugees are accommodated.

In order to prevent epidemics, the mobile medical teams frequently visit the refugee camps to screen the people for infectious diseases. It is necessary to inform the local disaster recovery management about the established treatment places in order to provide the medical care of those patients appearing at the scene after the team’s leaving as well.₂

Preparing adequate documentation and sending it to local authorities is essentially required. On Sumatra we did face individual tragedies: children or parents were killed in lot of families.₃ There was not enough time for us to deal with the loss of family members, but it made our work very difficult that some children were brought for medical visit without parents and/or without any information about their history. These children were supposed to be adapted by couples who lost their own children.

We were informed by the local authorities that rich western families without a child appeared and bid for the orphans. In these circumstances the continuous and reliable documentation of the patients is essential in order to prove the children’ identity and prevent them from a danger of child trade. The close cooperation with the local authorities is also needed.₄

Following the earthquake of a Richter magnitude 7.6 in Pakistan our team provided a medical and caritative service in the Kashmir region. Because of territorial conflict between Pakistan and India stretched to a breaking point, the area has become controlled by army, and we – adapting to the special situation – worked out of the ordinary. In such a situation, we were forced to follow the instruction of the army, and to ask for their help to reach the target area. We travelled from Islamabad to Balakot with armed escort and there worked in a closed camp controlled by the army. Because of the continuous shooting affairs visiting of villages did not seem to be safe. Controlled and documented entering had to be organized in the camp co-operating with the local organizations. In such cases special aspects had to be considered during the establishment of the examination place and the camp. Several examination places and a covered treatment place had to be chosen. Storage was needed to be placed not far, but separated and not accessible for patients. For rapid and easy usage and checking of shortage, store of equipments and medicines had to be arranged in a systematically way. (Considering the conditions of those people who lost not only their relatives but also their resources, we can understand why medicines and equipments can often disappear.)

In Pakistan two examination tents and a treatment place were built provided by the army. One of tents we bought served as storage. During the first three days we attended the most serious patients, then – during the two weeks we spent there – we made efforts to stabilize the patients’ conditions and transported them if required. Among others there was a four-year old girl with pelvic ring fracture who – after stabilization – was transported to a hospital 50 km apart.

There were a number of patients who did not required local, immediate health care. In our practice there were 10-15 patients in life threatening condition, about 200 severely ill patients and approximately 1000 persons attended the tent hospital because of lack of basic health care service. We had to prove them safety, well accessible accommodations. Furthermore it seemed to be necessary to ask for a security service or to organize our own guarding in favour of our own safety.

Our medical team had an other challenge on Java after the earthquake measuring 7.4 on the Richter scale in May of 2006. Local disaster recovery organizations called for medical care of patients marooned in mountain villages. Dividing into small teams we gave medical and caritative assistance in the villages within a 50 km area. For this purpose proper cars were needed. Three of the four teams visited the villages every day by car equipped by medicines and personal goods enough for one day, and patients out of chairs and beds were attended and treated. Transportation of the patients had to be organized in the field. The established base camp also served as surgery unit when required and offered help to the local organizations as well. In this base camp, one of our teams examined patients from schools and refugee camp located nearby. A special trouble was for us that our cargo had to go through several checkpoints before arriving.

In the past few years, inundations and floods occurred frequently in Hungary and in the neighbouring countries. Medical attendance in the area involved is of high importance during flood salvage. One function of medical team is the emergency medical care, the preventive medical services, however, proved to be also important (vaccination, screening for infections, separation of patients with infectious diseases, psychological service etc.). A 3-4-member team is able to provide a mobile medical care by boat or a jeep.

Medical attendance of people working on flood defence should also be provided. Based on our experience, an establishment of permanent examination places or mobile medical tents is also important. By communication means of the disaster recovery organization people have to be informed about medical care situated and functioned in the area.₅

Data about number of patients examined, incidence and severity of diseases, efficiency of treatment applied were continuously collected. We particularly focused on the efficiency of antibiotic therapy of infectious diseases. Incidence of complications of neuromuscular injections and the efficiency of their therapy was also monitored. Studies for cost-effective economic plans were carried out. After a mission we analyzed logistic and safety problems as well.

Our experiences and steps to be done are summarized as follows:

1. Personal and equipment requirements for the rescue, cargo

2. Preparing, packaging and authorization of cargo

3. Relationship with other organizations and consulates, authorization before travel

4. Tasks after arriving at the airport nearby the field

5. Transport of the equipments to the target field

6. Taking the equipments home

Logistic and supplemental duties

Prophylaxis

Requested safety and security equipments and roles in disaster area:

Workplaces and circumstances represent a high epidemic risk. Soil, clothes of patients, examination places mean an increased risk for medical staff. It is important not to approach the dining- and sleeping-places of the staff and to be particularly careful during taking a rest. Our clothes and shoes may be source of infections as well.

Food problems: Water, own food and heating require accuracy. Closed and bottled water are recommended to use for drinking and washing. Tinned foods originated from the host country may prevent the members of team from infections.

• Building of tent hospitals and accommodation tents (types, building techniques, problems and resolutions).

• Equipments needed, building the infrastructure (satellite, GSM communication, GPRS systems, GPS).

Difficulties of tropical and subtropical climates may serve as problems for storage of medicines, keeping the sterility of equipments and may cause difficulties for the members of the team as well.

1. High temperature and humidity characteristics of the climate can make resting and sleeping difficulties during night. Our colleagues needed approximately 7 litres of water daily, but lacked of appetite. Aftershocks – frequently Richter magnitude 6.0 – also disturbed sleeping.8

2. We have to face the problem of great temperature fluctuation when we work in mountains of subtropical regions. By day it can be 30°C or more, but during night it can reach freezing point.

For electric instruments highly effective accumulators or cheap and easily work generators should be used. Protective clothing/uniforms are helpful in preventing spreading of infectious agents. Collection and elimination of the protective clothes are highly recommended before team’s leaving.

If it is possible to establish more examination places, patients can be assorted based on the severity and separated, isolated. Treatments can be calculated, attendance can be made continuously if patients waiting for transport are placed separately.

In terms of size and accessibility of an earthquake-ridden area, logistic needs more organization, especially in case of small in numbers mobile teams work. In these situations, organization and medical care are carried out within hours.

It is more specific, precise and easier to operate a tent hospital in respect of attendance and logistic. Establishment of every place for medical care and fixed equipments accessible in case of a possibly occurring disaster since it is not necessary to move them, long term attendance is possible.

Rescue is followed by attention of media. Sensations are usually headlines, so rescues are considered as sensation by media. Several times consulates help in keeping the contact, in the field far from civilizations, however, medical care is often continuously filmed. Regulations similar to the rights enacted in Hungary and other European countries are not typical in Asian countries. We had no rights or possibilities to stop taking film. In fact, by an editing they can show us as persona non grata followed by expulsion or we can be brought to justice in worse cases. It is better to keep the written recommendation of the consulate with us, because it can help us in critical situations. It is desirable that always a spokesman should make reports, avoiding by this the contradictory answers. Taking photos and films is recommended for our report to be given on our work after returning home. A previously prepared report with photos should be handed over to media. In many cases those pictures were chosen by media which injured the rights of the patients or secrecy obligation.