(All photographs by Sara B. May)

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In the Wake of a Typhoon, a Surprising Discovery: Part Three

The third of a four-part account from the first medical relief team to be operational after last year's Typhoon Haiyan—in which things start to get really rough.
Jan 13, 2014· 9 MIN READ
David Page has written for The New York Times, Men's Journal, Skiing, Outside, and many other publications. He is a co-founder of Mammoth Medical Missions, Inc.

Long before first light we were up and at it, clearing debris, using an avalanche shovel to move sodden piles of paper, broken glass, pieces of shattered furniture, air conditioners, and computer equipment. It was Monday morning, Tanauan Town Hall, Leyte Province, Philippines, 72 hours after landfall of the most formidable cyclonic storm ever recorded. There was no roof on the building. We'd been traveling for three days. We'd promised the locals that we'd have a fully functioning field triage hospital with three operating rooms up and running on the second floor by 0800 hours.

The Office of the Registrar became the main supply room and pharmacy, mostly because it had a door that could still be locked even after team leader Mike Karch and Mike McMahon, one of our ortho techs, had broken into it using a Leatherman. Somebody from the mayor's office later provided the key. As gingerly as we could, we moved aside soggy, molding stacks of birth certificates and death certificates and marriage licenses. We cleared shelves, pushed desks together, stowed wet laptops in desk drawers, and began to unpack our supplies and equipment. We found a couple of sponge mops to move the slosh around. And brooms of a sort, made from palm fronds already thick with mold.

The Town Council chambers became the main operating theater. Somebody found a long pole that served excellently for lancing ceiling panels to drain standing water. We collected the stuff in buckets for Jon Bourne, anesthesiologist and self-appointed latrine master, to use for cleaning and flushing toilets. "If Jon hadn't done that, we'd all be sick or dead," said Wayne Anderson, another of our anesthesiologists, in retrospect. Wayne meanwhile stood on a desk and pried off panels from the ceiling above the center of the room. We used the panels to plow debris and water out into the hallway and from there down into the newly dubbed waiting room below. The locals pushed it from there out into the street. Desks became operating tables, covered with sheets of heavy architectural plastic someone had found in one of the offices. Large overturned bookshelves in the back room served as recovery beds.

Karch and Paul Chu (our third anesthesiologist) used duct tape to affix a small flagpole to the window grating in the council chambers, hanging the national flag out over the street. It seemed the right thing to do. Maybe it would help restore faith, boost morale, inspire civic sanity. Dozens of people were already gathered outside, lined up peacefully in the early light, watching us, waiting for things to get started. Contrary to the media's tendency to highlight chaos and violence after natural disasters, academic research indicates that social cohesion tends to increase and crime rates tend to drop in the wake of such events. Still, it became evident that Town Hall, such as it was, between our presence there and the unflagging energies of the medics and nurses and municipal staff downstairs, had come to represent a fairly convincing case for law and order, one that seemed to have a ripple effect on the greater population. There were demolished hospitals in Tacloban that had already been or would soon be relieved of their supplies and a mall that would get pilfered; in the town of Guiuan, where the storm had first made landfall, the mayor felt he had no choice but to legalize the commandeering of supplies from shops whose owners had escaped to Manila. We saw nothing of the sort in Tanauan.

The Planning and Development Office became the labor and delivery room. The local midwives brought their patients upstairs to where they could at last find some peace and privacy. (The following day a third midwife would show up to work. Her name was Golda. She'd lost her own four-year-old daughter in the storm surge.) A pair of local kids, camped out with their family in the Agriculture Office, helped scoop out some of the muck in exchange for a gallon of hand-filtered water and some of the stash of Halloween candy brought by Carson Bold, the 16-year-old son of one of our physician's assistants. Our hands grew soft and mushy. We wore gloves, as much as possible, to keep from getting cuts. Cuts meant infection. I already had a small one under way in my right eye, the product of some tiny stinging insect my eyeball had run into on the previous night's virgin run to the well, which offending object Karch had pulled out with his fingers. Before and after we touched pretty much anything, we washed our hands obsessively with hand sanitizer and, when that ran out, in a day or two, with alcohol.

On the landing at the head of the stairs, Dr. Sara May established a pleasant intake office and triage lounge using a bamboo screen featuring sun-faded Tanauan skimboarding photos and a pair of indestructible potted plants she'd scavenged from the wreckage. It wouldn't last but that one first day—when the rain kicked in again we'd have to tighten up the ship—but it gave everybody a point of reference for the way things ought to be. By 0600 hours a hot sun was shining through the rafters, drying out the ceilings and floors and making life seem not just possible but downright delightful. After a quick breakfast meeting (600 calories per person—meatballs with marinara sauce? pork sausage with gravy? sloppy joe? apple sauce, crackers, grape jelly), I put in a request with the army guys and also with the mayor's people for tarps of some kind so we could get some shade on our patio and in the O.R. Alan Podawiltz, our handyman, and Carson began a nonstop regimen of pumping water, liter after liter after liter, for us to drink and for cleaning wounds in the O.R.

By 0800 hours there were hundreds of people lined up in the street outside, the queue snaking around disabled vehicles and piles of crumpled roofing tin. Dr. Arlyn Santo and her troop of local doctors and medics were still at work downstairs—as they'd been to the best of their ability since the storm passed, now with help from a couple of Philippine National Police medics—dispensing what medicines and antibiotics they had left, helping people register their missing and dead. I gave them a list of what we could handle upstairs. It went like this: NO vomiting/diarrhea or psych problems; YES major trauma, non-illness-related abdominal pain, open wounds, unstable vital signs, inability to walk. Oh, and expectant mothers in labor. I asked that for the sake of calm and order and efficiency, only one patient at a time be admitted—in other words, allowed or helped or carried up the stairs to Sara's office. Despite the gravity of the wounds, there was no jockeying for position among patients. There were no altercations. Lavinia Orline, our nurse friend from Manila, and some of her friends and family showed up that morning to help translate.

The first amputation came 29 patients in. Her upper arm was crushed and infected. The anesthesia team used the battery-powered ultrasound to place a regional nerve block. Then Karch sawed her arm off. She didn't feel a thing.

Within the first hour it became clear that 90 to 99 percent of the cases we'd be handling would be Code Yellow—heavy trauma: crush wounds and lacerations inflicted by flying roofing tin, coconuts, and other storm-propelled projectiles, or punctures caused by stepping on sharp objects while trying to flee in flip-flops or bare feet. One hundred percent of open wounds were already deeply infected. Some were gangrenous. Looking back at the patient list, it went, in order, like this: Fendrick, penetrating abdominal trauma, right upper quadrant, and back laceration; Zosima, open right lower extremity fracture; Ritchie, left hand laceration; John P., right hand laceration; John C., left calf laceration; Guillermo, left femur fracture; Arnold, right thigh laceration; Florentina, right foot infection; Sonny, chest blunt trauma and left index laceration...

Wounds were irrigated, debrided, and dressed. The patients were given preliminary antibiotics and taught how to change dressings (and how to make fresh dressings from boiled T-shirts). They were asked to come back the next day for a follow-up. Scalp wounds, face wounds, elbows, toes, knees. Bone fractures were set under regional anesthesia, using spinal nerve blocks, splinted with pieces of window framing or whatever else was handy, and wrapped with duct tape and/or, while supplies lasted, fiberglass splinting material. Meanwhile, expectant mothers in labor walked up and down the hall trying to focus on their breathing.

The first amputation came 29 patients in. Her name was Burla. Her upper arm was crushed and infected with a deadly bacterial form of gangrene. She was on her way to dying in the next few hours. The anesthesia team used the battery-powered ultrasound to place a regional nerve block. Then Karch sawed her arm off. She didn't feel a thing. She walked out of the O.R. smiling, relieved, alive. She spent the night sitting in a chair in the downstairs lobby with her family. On his rounds that night, at 0200 hours, Karch was pleased to find her awake and well and "not at all in pain." Later, on Wednesday afternoon, with the assistance of Team Rubicon, we would manage to get her and several other acute cases evacuated by truck and helicopter to Tacloban and from there, we hoped, to a hospital in Manila, where she could undergo a completion amputation to close the wound and maybe even get fitted for a prosthetic. The next amputation came eight patients later.

Supplies were a major issue from the beginning. We knew we could only last a few days with what we had. We found a stack of hardbound ledger books and dedicated one to a running wish list that we would periodically tear out and hand to anyone who asked if we needed anything. Then we'd start another one: bleach, mops, misoprostol (for labor induction), "as much Keflex (cephalexin) as you can get," ketamine (anesthesia), alcohol, clean water, generator, 4x4 sterile gauze dressings, any size sterile dressings, propofol, Cipro, hand sanitizer, Coca-Cola (for hydration and flavor—we didn't yet know that the town's primary industry was a Pepsi bottling plant), lidocaine, blades, size 8 sterile gloves, saline solution...

One of these lists we handed to an American fellow whom we came to call Pastor Jack. Jack was originally from Denver. Now he lived somewhere up in the northern islands and ran an orphanage. He'd come down to Leyte and managed to get a car and was driving around doing what he could. He had a boy with him, Robin, who'd somehow lost his mom and dad earlier in the year, up in Manila. Robin had only recently learned to speak English. He apparently had brothers and sisters who weren't interested or capable of taking care of him. Carson inducted him into the rich and complex world of Extreme Sour Warheads candy. Over the next few days he became a kind of mascot to us. We tried to tell him about Batman.

Pastor Jack brought us news of the outside world. It seemed, at that point (on day 4), that we were the only functioning hospital in the region. The main public hospital at Tacloban had been ransacked. (We would later hear that of the 217 patients in that hospital when the storm hit, 211 died.) As far as he knew, there were not yet any other foreign teams on the ground. (It would be another two days before the first Médecins Sans Frontières [a.k.a. Doctors Without Borders] medics were up and running with their field clinic in Guiuan.) People were hungry, Pastor Jack said. Starving. For a city of 50,000, they'd so far managed to deliver 30 sacks of rice—one of 20 truckloads that had arrived by air in Tacloban, 16 kilometers away via a road that had barely been cleared. "That's one sack of rice for every 1,600 people," he said. The good news was that there was a gas station that had gas and was trying to reopen for business. The bad news? The place was surrounded by 2,000 motorcycles.

Lavinia introduced me to a woman by the name of Geline Avila who lived around the corner. She'd lived for years in Oakland, Calif., before returning to Tanauan. "I'm 59 years old," she said, "and I've never seen our society fall apart like this. It changes everything to have you here." She understood that for the line to hold we would need supplies. Sooner rather than later. She had a good friend who was a doctor at a Catholic hospital in Tacloban—St. Paul Divine Word—that may also have been ransacked and was in any case not functional. She thought that maybe if I went with her and her doctor friend, and maybe the mayor too, we might be able to procure some supplies. Then she explained that it might take us two or three hours to drive there. That never happened.

If we'd had a better communications setup, a better list of contacts, and a person dedicated to it, we'd have been able to open a supply chain from Tacloban. Karch managed to get a full report through to his wife, at home in Mammoth Lakes, Calif., twice daily, to keep our families apprised, and at some point I got a series of truncated calls through to an assignment editor at an ABC affiliate in Los Angeles. I ran into two people from the Philippine Red Cross, in uniform. They were walking from town to town, they said, assessing the damage. I told them our situation. They took note of it. Pretty much we were sending messages in bottles. Here's one I hastily wrote out to give to Dr. Duds Santos, our escort/attaché from the PNP, when he left for Tacloban that first day we were seeing patients. I thought maybe he'd find Liebrich, the Army Ranger who'd helicoptered in with us:

Attn: Leo Liebrich. Major, U.S. Army.

Leo—

We are set up and operational in Tanauan, Leyte. We have established command center and processing approx. 60 patients per day. We could work round the clock with generator. We are pumping water adequate for team but need drinking water as soon as possible. We have MREs for another ~3 days. Hoping for logistical/personnel relief and evac for team Friday night or Saturday if possible. We have some local police security and are coordinating with PNP for more—as they can spare. Quiet here, for now. But intel re: looting local hosp.