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The terror attack on Bali, 2002 – KAMEDO-report 89

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.

Summary

Introduction

On October 12, 2002, shortly after 11 pm, two bombs exploded on the island of Bali in Indonesia. Two bars in the tourist district of the holiday resort Kuta Beach were totally destroyed.

The explosions claimed the lives of 202 people from 21 different countries and more than 300 people were injured. Most of them were tourists. The injured were initially taken to different hospitals and clinics on Bali. The majority were treated at the largest hospital on Bali, the teaching hospital Sanglah General Hospital. They were treated by the regular staff at the hospital, with the support of volunteers. Eventually, reinforcements arrived in the form of medical teams from other Indonesian hospitals and from abroad.

The most seriously injured foreign nationals, 135 in total, were evacuated by air during the days immediately after the bombing. Most were flown to Australia, 10 or so were flown to Singapore and a further 10 or so were flown to other places.

The Australian Air Force (RAAF) evacuated a total of 66 patients from Bali to Darwin over a 21-hour period. Following stabilisation and emergency treatment at the Royal Darwin Hospital, the 40 most seriously injured where flown by civilian air ambulance to different burns unit in Australia. The RAAF made a further four flights from Bali, carrying 35 persons with slightly less serious burns.

The observers' experience and conclusions

Efforts on Bali

Explosion and fire

Eyewitness accounts report the terrible scenes following the explosion and from these accounts it can be seen how quickly after the explosion the fire must have spread. Several people report how small groups of people held each other's hands and in the darkness tried to make their way out of the collapsed building. The first person to get out escaped with minor injuries, the second also managed to escape but with serious burns – the third didn't make it out.

Comments: In this type of incident, fire spreads very quickly. It is vital that evacuation routes are clearly marked and that these are adequate for the number of visitors.

Pre-hospital care

The rescue work and transport of the injured were carried out largely by volunteers. The injured were transported from the scene of the explosion as soon as they were found. The ambulances had neither the personnel nor the equipment to provide advanced medical attention at the scene. Reports from the incident describe how the injured died in the arms of the rescuers.

Comments: This description indicates that the majority who died at the scene died of serious injuries to organs with haemorrhagic shock, rather than respiratory problems or similar complications. It is therefore not particularly likely in this case that the number of early deaths would have been reduced if the injured had been taken care of by paramedics as would be the case in western countries. However, had there been treatable injuries more lives could have been saved if more advanced ambulance medical care had been available.

Prioritisation and supervision

No triage was carried out at the scene of the explosion and instead the injured were transported without any sorting process taking place. Initially, dead bodies were also taken to the emergency department, which further increased the pressure on the department. The lack of co-ordination in conjunction with the transport of the injured, as well as the lack of means of communication, meant that the emergency department at Sanglah General Hospital could not do anything about the chaotic situation. They had no contact with the ambulances or the scene of the explosion.

Comments: Triage, co-ordination and a good communication system could tangibly facilitate treatment of the injured and reduce the pressure on the receiving hospital in chaotic situations. Communication is also a weak link in Swedish healthcare and ought to be developed.

Medical care co-ordination was not organised at the scene. Had this been the case, the directing of patients to different hospitals in the area would probably have been better, which would have at least reduced the influx of less seriously injured persons at Sanglah General Hospital. However, there was a lack of a control structure and technical means of communication for those in charge of medical treatment.

Comments: It is important to at an early stage establish a control system at the scene of an incident which distributes the injured in such a way that not all are sent to one hospital. From a Swedish point of view the work that has recently been done on developing the “control of medical care at the scene of an incident” function would be of considerable value in this type of incident.

Work at the hospital

Sanglah General Hospital became overloaded. On the other hand, there are few hospitals in the world, if any, that could have handled such a large influx of seriously injured patients. Monitoring equipment, medicine, consumables, sterilised instruments, linen and so on ran out. The hospital management and volunteers tried to solve these problems in different ways, among other things by attempting to find support from organisations outside the hospital, mainly the hotels.

Comments: It could be of value from a Swedish point of view to identify the potential capacity of volunteers or private companies to make equipment available in an emergency overload situation.

Apart from the medical personnel employed at the clinics in the area, a large number of volunteers helped with the injured at the hospitals – both Balinese and foreign tourists, people who had no medical training whatsoever, as well as medical personnel on holiday on Bali.

Comments: The overload on the medical system on Bali meant that they needed all the qualified help they could get. Sanglah General Hospital found itself in a particularly difficult situation as it received the majority of the injured, including most of the tourists. This, in combination with a lack of interpreters and the arrival of foreign volunteer medical personnel, led to a situation that was difficult to control for the hospital management.

None of the senior doctors at the hospital appeared to have been in a position where they could lead the voluntary work – neither during the night nor during the day after the bombing. If this had been the case the volunteer doctors could have worked directly under the doctors at the hospital. This would probably have reduced both the legal difficulties and the friction that arose between the hospital and the volunteer groups. There is reason to consider how the Swedish medical system would handle a similar situation.

Most of the patients had not been prepared in any way, such as being undressed or bandaged, prior to operations and wound assessments. Nor had any patient been identified. To maintain order among the patients a number was written somewhere on uninjured skin. This number was then used when the patient was reported to the nursing ward. The medical documentation was very brief.

Comments: Even in chaotic situations case-books and identity tags should be used. If these were to run out or not be available, a plan should be in place for how this is to be handled.

Australia's efforts in conjunction with evacuation by air

World perspective of the medical evacuation by air

Australia was hard hit by the bomb attacks on Bali – apart from the 83 Australian nationals who were killed there were also 129 Australians among the injured. It was thus important for those responsible in Australia to act as quickly and efficiently as possible to evacuate the country's citizens. In this case the rapid evacuation and repatriation took place by air in two stages. This involved considerable geographical spread and extended across several time zones.

Comments: In the event of evacuations by air involving several time zones it is vitally important to clarify at an early stage the times that are used in conjunction with communication and the keeping of records. Probably both local time and UTC ought to be given. This became very clear during this incident but also in connection with the Swedish evacuation of injured persons from Thailand following the tsunami in 2004.

Many Australians were killed and injured in the terrorist attacks in New York, USA on September 11, 2001. After this, a complete review was made of the contingency plan for incidents involving large numbers of Australians abroad. The result was a new way of reacting to global events – the Global Response monitoring system. One of the components in Global Response is the rapid activation of an emergency call unit with 12 switchboard operators. These can mediate calls to up to 700 specially trained government officials in Canberra. In conjunction with the bomb attack on Bali this function was activated at 6 am (4 am Balinese time) to receive calls from anxious relatives. At the same time, information regarding the incident was posted on the Department of Foreign Affairs and Trade website. The website also had the number of the emergency call unit, urging Australians to call and provide information about their relatives.

Comments: Australia's Global Response monitoring system is an interesting means of providing the country's citizens with help in the event of a major incident abroad. Sweden could benefit from studying in more detail how the system has been built up and learn from Australia's experience.

During the first 24 hours after news about the explosion was received from the Australian consul on Bali, the Australian Department of Foreign Affairs and Trade identified 113 injured Australians by checking hospitals, hotels and the airport. Through the consulate on Bali it was proposed to the Indonesian Minister for Health that the injured should be evacuated to Australia by the Australian Air Force (RAAF). No formal request for assistance was ever made by Indonesia. It was more a “formal invitation to Australia to help” as the Australian Department of Foreign of Affairs and Trade put it. The basis was the extensive collaboration between the countries at an administrative level that has been in place for a long time in many areas, including among others the Australian Federal Police (AFP).

Comments: From a diplomatic point of view, it is common practice that aid from one nation to another is preceded by a formal request for assistance, which did not take place in this case. It was more a case of a “formal invitation” to Australia to help. Deviation from practice represents a breach of the other country's sovereignty, which is particularly sensitive if military resources are used, e.g. in connection with air transport. In this case the invitation to help was obviously equated with a formal request for assistance. What was unusual in this case was that the aid was primarily for affected persons from their own country – it was thus not a general aid effort. The same applied for the Swedish evacuation following the tsunami in Asia in 2004. However, it can be maintained that evacuation of a large number of foreign injured persons releases medical resources that could instead be used by the citizens of the country affected, which means that the aid effort has a more general effect.

Evaluation of security, information and leadership during medical evacuations by air

At the time of the bomb attack on Bali there was no plan in place for how Australia would deal with a large number of its citizens being injured in a neighbouring country. The evacuation on Bali was more the work of energetic individuals, particularly during the early stages, rather than a co-ordinated response from a geared-up organisation. In formal terms, responsibility for citizens abroad rests with the Department of Foreign Affairs and Trade but it does not have any transport resources. The only organisation with resources to implement a large-scale evacuation of injured persons was the RAAF. The solution was that military aircraft were used to fly civilian patients out.

The medical equipment, however, gave rise to a number of problems as it was not adapted to the versions of the C-130 used during the assignment. Nor did the equipment have the battery capacity for a protracted assignment such as this. Furthermore, there were no transformers to allow the equipment to run on electric power taken directly from the aircraft; this has, however, since been corrected. Nor were there any adapters for the electricity sockets on Bali.

Comments: This illustrates from a Swedish point of view the question of airworthiness and patient safety and ought to be compared with how aircraft with medical equipment and personnel were handled in conjunction with the tsunami, where in many cases there was neither certification of the equipment brought, nor approved attachments for the medical equipment. SNAM-light with military stretchers in an MD 80 was an exception to this, with approved stretcher stands and airworthy medical equipment.

It is obvious that the central planning of the evacuation from Bali was based on unsatisfactory information and there was a shortage of expertise regarding transport of injured persons by air.

Comments: It is conceivable that a rapid response team (RRT) with specific medical equipment could have been sent quickly to Bali by jet. This team could have produced ground for planning, it could have commenced the aid work and it could also have prepared the evacuation at the airport.

It was decided to charter a smaller civilian jet that was available on Bali to transport the most critically injured patients. This could be ordered thanks to the fact that the Department of Foreign Affairs and Trade had access to USD 75,000 which could be used in an emergency for transport by air ambulance. Following a request for dispensation for the aircraft (for noise reasons) it could fly directly to Perth.

It has been difficult to obtain information concerning who made the decision to use the civilian aircraft, which was the first to leave Bali. Likewise, it has been difficult to find details about what happened to the patients during this transport.

Comments: The above illustrates from a Swedish point of view the question of who makes the medical evacuation decision and who assumes responsibility for medical care. Both in Australia and in Sweden the state lacks the potential, or has very limited potential, to in peacetime take over the control of medical care in connection with serious or extraordinary incidents. This is obviously a weakness regarding incidents that are of such magnitude that national co-ordination of resources is required. It ought to be compared with how certain aircraft were handled during the evacuation by air of injured persons to Sweden in conjunction with the tsunami disaster. In that situation the National Board of Health and Welfare assigned responsibility for medical care to a specified county council during the SNAM-light flights, whilst other aircraft flew patients undergoing Swedish medical care without clarification of the liability issue.

The airline Qantas spontaneously organised extra evacuation flights for a large number of less seriously injured and uninjured persons.

Comments: Forceful action by a large airline to contribute to the evacuation of less seriously injured and uninjured persons should be considered an asset although this ought to be co-ordinated with the national operations team. In order to handle this type of incident effectively at an early stage, a primed operations team ought to be in place on a national level.

Logistics during medical evacuation by air

When the first Hercules plane landed on Bali the crew was met by a representative from the Department of Foreign Affairs and Trade. The representative stated that a number of injured persons had recently been flown out on a private jet bound for Perth. There were no injured persons remaining at the airport. It was stated that the most seriously injured were at Sanglah General Hospital, a 40-minute drive from the airport.

A doctor and two medical assistants were given the task of setting up an assembly point at the airport. The rest of the team drove to Sanglah General Hospital in the same vehicle that brought the representative from the Department of Foreign Affairs and Trade to the airport. The three satellite telephones which had been brought were given to the doctors so that they could maintain contact between them, the hospital in Darwin and top ranking air force staff.

Comments: With regards to the Swedish air ambulance SNAM this is an important experience. Injured persons can be spread out among several hospitals, which requires a special logistics system with the ability for those evacuating to locate different hospitals in order to take over the medical care there. This requires the presence of means of communication, to maintain contact between the aircraft and the groups that set off to collect patients.

When the first Hercules plane landed in Darwin it was met at the airport by a team from the Royal Darwin Hospital, comprising anaesthetists, intensive care nurses and doctors from the medical air evacuation team. Management on site was exercised by the head of the hospital's anaesthesiology department. He was able to maintain contact by mobile phone with an ambulance officer who checked that empty ambulances arrived at 3-5 minute intervals. The doctor also had contact with the head of the emergency ward at the hospital to report who was on the way in.

Comments: The organisation for reception at the airport can be cited as a good example of how logistics and communication ought to take place. This model is well worth incorporating into Swedish contingency plans.

Several air ambulances were parked at Darwin Airport although these could not be used before the crews had their stipulated rest periods.

Comments: As soon as a need for air evacuation has been noted in which long flight times are involved, resources ought to be sent so that the pilots can have their statutory rest period prior to making the medical transport flight. There are no equivalent rules for the medical personnel but of course rest is equally important for this group which should be taken into account prior to a long medical transport assignment.

On the Monday, various civilian air ambulance operators arrived at Darwin Airport, including the Royal Flying Doctor Service. According to the Royal Darwin Hospital they came on their own initiative, without liaison. In several cases the crews of the civilian air ambulances tried to take over control of the work at the airport and on two occasions there was some confrontation between the civilian air ambulance crews and the team from the hospital in Darwin. Only in two cases was there direct reloading, in both cases of patients who were considered to be in a stable condition.

Comments: The situation that arose at the airport in Darwin could very well arise anywhere in the world, including Sweden or anywhere Swedish air ambulances are involved abroad. The role of co-ordinator is extremely important in situations such as these. This role ought to be filled at an early stage by a more experienced person who is trained for the assignment and who has an insight into both air operations and medical matters.

The Australian aircraft with injured persons flew to Darwin. The Royal Darwin Hospital was used as a collection point/staging facility. The volume and quality of the care provided at the hospital in Darwin was impressive and was based on solid training and exercises.

Comments: This illustrates the importance of exercises, training and team spirit. In this way an impressive contribution was made by a relatively small hospital.

 

At the hospital in Darwin they had 12 hours to make preparations, from the time the decision was made to help until the first patients arrived. This time was used for recapping on the training along with planning and preparing for the work to be done. They also thought ahead by sending home some of the staff to rest. They were not as forward-thinking with regard to their own supervisory team and other key persons.

Comments: The capacity to use the time rationally for preparations and rest ought to be taken into account.

Through a carefully considered combination of personnel with varying degrees of experience, it was possible to make optimal use of the more experienced personnel at the hospital's emergency department. In addition, they also worked in separate rooms; in each room there was a consultant who was responsible for prioritising resources. At the emergency ward and the intensive care unit there were also senior physicians in charge. All information to and from the hospital management was channelled through these departmental consultants.

Comments: This working method could be worth testing in the Swedish healthcare system.

Special transport-related problems

Reports show how patients with burns who had undergone emergency surgery (fasciotomy and escarotomy) began bleeding again from their wounds during the flight. The reasons for this are unclear although vibrations or a fall in body temperature during the flight could have been contributing factors.

Comments: The problem of renewed bleeding during transport could be attributed to vibrations although another possible explanation could be the effect of low temperature (hypothermia) with the subsequent impact on coagulation. One could initially be misled into believing that it is warm on a plane. The temperature during transport is far from 37°C, perhaps 20°C at best, and this, combined with a long flight time, could very well lead to hypothermia in seriously injured patients, particularly those with burns with major heat loss as a result of fluid evaporating from the damaged skin.

The Australian Air Force used Hercules planes for the assignment. The medical equipment which was taken on board was not certified for the versions of the aircraft type used (C-130 J and C-130 H). This entailed a risk from an airworthiness and patient safety point of view.

Comments: It is important that certification takes place to ensure both air safety and patient safety.

 

Only three patients had been intubated prior to or during the long flight from Bali. However, within an hour of arrival at the hospital in Darwin a further 12 patients needed to be intubated. All these had burns to the face and respiratory system. The problems in the respiratory system were ascribed to rapid swelling as a result of the patients suddenly receiving fluid replacement.

Comments: The above is an interesting observation. It could be that fluid replacement according to Parkland's formula produces a side-effect in the form of noticeable swelling in the respiratory system, which could be very difficult to handle in a transport situation. This raises the point of considering giving less fluid replacement, before and during transport, as compared to the customary treatment models, as long as the patient is not intubated, in order to avoid serious respiratory problems in non-intubated patients during the flight.

Whether this affects the survival rate in the long term is unknown but it should be weighed against the fact that the patients in this case arrived at the hospital in Darwin alive. This area ought to be the subject of further evaluation.

The work at the Royal Darwin Hospital in Australia

There was never a shortage of blood at the hospital but to avoid confusion it was decided to consistently use 'disaster identity numbers' when requisitioning blood as many foreign citizens were expected among the patients. Despite this, certain employees began after a while to use the patients' names, which led to confusion and uncertainty in the handling process.

Comments: This illustrates the importance of maintaining one identity labelling system.

Groups of specialists in internal medicine and general practitioners monitored and followed up the fluid balance of the patients on the wards. These groups relieved the surgeons and anaesthetists. At the same time, the feeling that everyone at the hospital was involved in the work was reinforced.

Comments: Also in Sweden the equivalent expertise within internal medicine and general medicine ought to be used.

Reflections on aid to citizens abroad

Australian authorities and companies have not claimed any compensation for their efforts – whether it be medical care or for the air transport of foreign citizens.

Comments: The cost of the help Swedish consular missions could provide to Swedish citizens abroad is often claimed back from the person in question. Assistance organisations only help those who have travel insurance through an affiliated company. There is thus no general obligation to help Swedish or Scandinavian citizens.

The staff at the Swedish consulate expected that SOS International would act more rapidly and with less bureaucracy as the situation was chaotic.

Comments: SOS International is a privately owned assistance organisation, based in Copenhagen and charged with the task of bringing home sick and injured persons insured through Scandinavian insurance companies. The company name SOS International brings to mind our domestic emergency call centres – SOS Alarm. This probably leads many Swedes to believe that the organisation's services are a benefit that is available free of charge to Swedish citizens in need of help abroad, not just policyholders. This is, however, not the case.

Experience pertaining to the air ambulance service in Sweden

  • National crisis management in Sweden came into focus following the tsunami disaster in Asia in 2004. How Swedish National Air Medevac (SNAM) can be activated rapidly in conjunction with the evacuation of Swedish citizens abroad must be clarified before this resource becomes operative.
  • SNAM is based on the principle that the patients who are to be transported have received adequate emergency care. The events on Bali, however, illustrate that one cannot always assume this. SNAM must be provided with materials so that, if necessary, it can take emergency measures and prepare or stabilise injured persons prior to them being transported by air.
  • There should be technical resources available to allow patient data to be transferred between the aircraft and the receiving hospital.
  • Frameworks for co-operation between SNAM and the SOS International emergency call centre and other assistance organisations ought to be clarified.
  • SNAM is a civilian, not a military, resource, which should be an advantage from a diplomatic point of view.

 

Authors

Pepe Brolén
Per Örtenwall
Håkan Österhed
Helge Brändström (editor)

 

 

 

Read the full Summary

Year: 2007
Article number: 2007-123-35
Format: POD
Pages: 102
Language: Engelska
Price (VAT included): 98 kr

Contact

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+46 (0)75 247 30 00