Plastic Surgery Resident Living in the Pacific Ring of Fire

by M. Rachadian Ramadan, M.D., BMedSci
Plastic Surgery Resident, University of Indonesia,
Ciptomangunkusumo National Hospital, Jakarta, Indonesia


Last July, our beloved island of paradise and one of Indonesia’s popular tourist destinations, Lombok, was struck by a 6.4 magnitude earthquake.It did not stop there, as a series of more than 750 tremors, most notably a 7.0 magnitude earthquake, followed in the week after the first earthquake.The death tolls reached over 500, more than 2000 were injured, and around 500,000 Lombok citizens were displaced from their homes.These events have triggered national responses, as hundreds of government organizations, universities, hospitals, and NGOs sent their relief. This included the medical team from the Indonesian Association of Plastic Reconstructive and Aesthetic Surgeon (InaPRAS).

Recalling other disasters in Turkey, Haiti, and Chile, plastic surgeons have played a fundamental role in managing the acutely injured victims of mass disasters.4-6 In response to the Lombok situation, InaPRAS assembled a medical relief team consisting of plastic surgeons, plastic surgery residents, scrub nurses and social workers, under the leadership of Dr. Guntouro, a plastic surgeon from Gatot Soebroto Military Hospital, Jakarta. The team assisted with plastic reconstructive surgery services for the victims, especially in managing soft-tissue-related injuries, burns, and facial traumas.7

Living as a plastic surgery resident in the Indonesian archipelago, where Lombok Island (and Bali) are inside the “Pacific Ring of Fire”—defined as the line of extreme volcanic and seismic activity spread across Pacific Ocean—I should have realized that disaster like this could happen monthly, weekly, or even daily. The broadcast message came to my phone: Faculty were asking if any residents were willing to volunteer for the Lombok mission. That was when I suddenly recalled my graduation day. As a medical doctor, there I said, “I solemnly pledge myself to consecrate my life to the service of humanity,” the first sentences of the Hippocratic Oath.I decided to become a volunteer, not for the experience—as I would never risk my life working in the active earthquake region just for the experience—but for the service of humanity as a medical doctor, as a plastic surgery resident.

Long story short, I was able to go to Lombok earlier than the InaPRAS team. The team leader appointed me as part of the “Advance Team” who assisted one local plastic surgeon in Lombok, Dr. Badriyatul Haya (Dr. Aya), to initialize the plastic surgery services center across Lombok Island, just before the main team arrived with all the equipment, implants, instruments, and surgical logistics. The second 7.0 magnitude earthquake struck just one night before my plane departed from Jakarta. I got news that the whole island was totally blacked out from electricity, there was no water available, no market, no ATM nor bank, and buildings were unsafe to inhabit. The rule of thumb was, before saving others, I must be able to save myself first. So, then I started to pack, preparing my survival kits for the worst that could be happen. I packed a sleeping bag, headlamp, raincoat, and I packed food and a water bottle inside my backpack. Those kits prepared me to sleep under the skies, as sleeping under a roof would be ultimately unsafe in an active seismic region. I thought that I would probably do some acute plastic surgery care in the field, so I also brought my Plastic Surgery instruments, archbar, wires, 3.5x surgical loops, and several thread sutures from 3.0-8.0.

I arrived in Mataram, the capital city of the province. The city was quiet, and people were staying outside their homes, inside tents. However, not much damage was noticable, since the center of the earthquake was on the north side of the island. I went straight to West Nusa Tenggara Central Hospital to meet Dr. Aya, the local plastic surgeon. Here we encountered our first problem: all of the hospitals were down. No operating theatre was available due to damaged building from the recent 7.0 magnitude earthquake, so where were we supposed to operate? Meanwhile, dozens of governments medical organizations and NGO also sent their help to Lombok, so we came up with the idea that we may collaborate with them and join their operating theatre.

The next day, we acquired the information that the Indonesian National Navy were docking their Hospital Ship on the North shore. We went to North Lombok, and the catastrophes (Figure 1) became clearly visible: all building leveled down and victims staying in tents, salvaging for foods, supplies, and medical help. Most access to remote villages were blocked due to landslides and broken bridges; they had not received much help at that time.

Figure 1 - Ramadan

Figure 1. Leveled house and building in the center of earthquake region

After 4 hours of driving, we arrived at the Dr. Soeharso Military Hospital Ship (Figure 2), which is equipped with 3 fully functional OTs and 50 bed surgical wards.Luckily, we were able to cooperate with the hospital director to use the OT for the upcoming InaPRAS team, especially for those victims around North Lombok that were too far to transport to the capital cities. On our way back to Mataram, we got word that the West Nusa Tenggara Central Hospital had acquired a donation of three In-container Field Surgical Suites and two OTs at Wirabhakti Military Hospital, also now fully functional. Shortly after, we collaborated with the three centers mentioned to use their OT for the upcoming InaPRAS team (Figure 3).

Figure 2 - Ramadan

Figure 2. KRI Dr. Soeharso Hospital Ship, docking at Carik Harbour, North Lombok

Figure 3 - Ramadan

Figure 3. Plastic Surgery centers across Lombok Island, during InaPRAS mission 13-25 August 2018

The InaPRAS main team finally arrived two days later, bringing all the plastic surgery equipment, and started to operate around these 3 centers across Lombok. We mostly collaborated with orthopedic surgeons to handle the reconstruction of soft tissue injuries, facial trauma, and burns. Microsurgery cases are also present. Within 12 days, the InaPRAS team perfomed 33 plastic and reconstructive surgeries for acute earthquake victims (Figures 4-5). This number kept increasing since the local plastic surgeon stayed there and continued to perform the services.As we operated, small tremors continued to shake 20-50 times daily.

Figure 4 - Ramadan

Figure 4. InaPRAS team operating in KRI Dr. Soeharso Hospital Ship, Bayan Harbour, North Lombok

Figure 5 - Ramadan

Figure 5. InaPRAS team operating in Field Container Surgical Suites, West Nusa Tenggara Central Hospital, Mataram, South Lombok

In contrast to popular belief that plastic surgery only deals with cosmetic surgeries, the plastic surgeon often comes back to his or her roots as medical doctor that serves humanity. They are well-trained for acute trauma and modern disaster management. The role of plastic surgeons inside multidisciplinary disaster-trauma teams are unique and improve the assistance of victims requiring plastic reconstructive surgery services.10

As I wrote this, another 7.4 magnitude earthquake with a tsunami, hit Palu City, of Sulawesi Island, Indonesia.11 Being a plastic surgery resident living in the “Pacific Ring of Fire,” one must be ready at all times to fulfill the first sentences of the Hippocratic oath they have sworn.


References
1. Mitchell McCluskey, Angus Watson, Susannah Cullinane. Lombok earthquake: 14 killed on Indonesian tourist island: CNN; 2018 [cited 2018 29 September]. Available from: https://www.cnn.com/2018/07/28/asia/indonesia-earthquake/index.html.

2. Hilary Clarke, Dewan A, Smith R. Landslides, debris hinder Lombok quake rescue efforts: CNN; 2018 [Available from: https://www.cnn.com/2018/08/07/asia/lombok-earthquake-indonesia-intl/index.html.

3. LOMBOK EARTHQUAKE UPDATE: BNPB; 2018 [Available from: https://bnpb.go.id/english-lombok-earthquake.

4. Clover AJP, Rannan-Eliya S, Saeed W, Buxton R, Majumder S, Hettiaratchy SP, et al. Experience of an Orthoplastic Limb Salvage Team after the Haiti Earthquake: Analysis of Caseload and Early Outcomes. Plastic and Reconstructive Surgery. 2011;127(6):2373-80.

5. Prado AS, Reyes S. Plastic Surgeons’ Performance during the February 27 Earthquake in Chile. Plastic and Reconstructive Surgery. 2010;125(6):1835-7.

6. Wolf Y, Bar-Dayan Y, Mankuta D, Finestone A, Onn E, Morgenstern D, et al. An Earthquake Disaster in Turkey: Assessment of the Need for Plastic Surgery Services in a Crisis Intervention Field Hospital. Plastic and Reconstructive Surgery. 2001;107(1):169-70.

7. InaPRAS. Baksos Operasi Rekonstruksi PERAPI untuk Lombok 2018 [Available from: http://perapisurgeon.org/news.php?top=1&menu=view&id=90.

8. Declaration of Geneva (1948). Adopted by the General Assembly of World Medical Association at Geneva Switzerland, September 1948.

9. APCR 990 KRI Dr. Soeharso (Multi-Task Ship / Hospital Ship) [Available from: https://www.globalsecurity.org/military/world/indonesia/lpd-tanjung-dalpele.htm.

10. Thakar HJ, Pepe PE, Rohrich RJ. The Role of the Plastic Surgeon in Disaster Relief. Plastic and Reconstructive Surgery. 2009;124(3):975-81.

11. Nicole Chavez MA. Indonesia tsunami and earthquake kill 384, leave hundreds injured 2018 [Available from: https://edition.cnn.com/2018/09/29/asia/indonesia-earthquake/index.html.

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