sBMJ | The eye of the storm

The eye of the storm

Bala Karunakaran went to Kilinochchi Hospital in northern Sri Lanka to help set up a maternity operating clinic and research how the region had been affected by civil war but found himself in the midst of a huge emergency relief operation. He shares his experiences of the tsunami

FREDRIK NAUNAN/PANOS

We headed to the hospital in the early morning. We saw many Tamil Tiger rebels walking around with walkie-talkies and stiff faces. We approached and inquired further about it. A rebel commander told us that he had heard reports of the sea coming into villages and promised to keep us updated. We did not think much of it. I thought a lot of property would have been destroyed and felt sorry for the people, but we could not imagine the extent of this tragedy.

By 8 am, we were getting reports that the tragedy was far worse. The rebels were rushing people to hospital in buses, lorries, and on motorbikes. Many were pronounced dead on arrival. The outpatient department was overfull, and we got reports that the situation was only the tip of the iceberg and that a lot more people were coming. Soon the hospital was teeming with people. Doctors stopped trying to keep medical records. The district medical officer, Dr Sathananthan, realised that if this were to continue there would be no room to treat anyone. He contacted a rebel commander to vacate a nearby school for us. The hospital uses a colour code system--something learnt from the war days, when they have to deal with masses of injured people. All volunteers and staff were given red armbands, and no healthy people were allowed into the hospital without one. Patients with urgent injuries got a yellow armband, and volunteers took them to the wards. Patients with minor injuries got a green armband, and they were transferred to a nearby school to be treated by medical students. The hospital has 125 beds and at least an estimated 700 people were in the hospital at that moment.

Fighting the tide

Most of the patients were in shock. Many who had nearly drowned were hyperventilating. Patients with serious injuries were agitated and were attempting to get out of their stretchers to find their missing relatives. Many were dazed and were trembling as they spoke. Most injuries were cuts from palm leaves, fences, and barbed wires, but the only reason these people had survived was because these had caught them. Many people also had multiple fractures from being tossed against buildings by the tide. Most people were trying to comprehend the 12 m waves that rose higher than the palm trees and had swept away their villages. Entire families had been swept out to sea.

The operating theatre was lacking in facilities even before the tsunami; now it was overstretched. Most surgical instruments were missing and doctors had to improvise. The theatre did not even have an anaesthetics machine. Doctors who were not surgeons were helping out in whatever way possible. The medical unit of the Tamil Tigers, with their experienced trauma surgeons, was on site operating as well. Most operations had to be done in the corridor, and a queue of people was waiting. The theatre was running out of essential medicines and items, like gauze, and the hospital had to send people to non-functioning private hospitals in the region and scrounge for medicine and equipment.

Blood bank

A tent was erected in the courtyard for assessing patients and for those who had to be transferred to the nearby school. The local police force arrived and guarded the hospital gate. A loudspeaker gave people and volunteers instructions, establishing some control. Media crews from television stations for expatriates abroad arrived. A local charity, the Tamil Rehabilitation Organisation, sent volunteers to help in the hospital and also established a temporary refugee camp for displaced people. As the hospital lacked a blood bank, it had to appeal for immediate blood donations to cope; local people queued up and donated. Within two hours the hospital had more blood than it needed, and donors were turned back disappointed.

Some critically ill patients had to be transferred to other hospitals that had better facilities. These were in army controlled areas and were a two and half hour ride away. Patients were registered before being transferred. Some children needed to be transferred immediately. Most of them were unable to speak as they were in a state of shock. I was asked to photograph them with my digital camera--the only record kept of these patients. I also photographed all the children who were in shock and could not identify themselves.

Doing it by the book

By this time the mortuary was full, and bodies were put in the administrative building of the hospital. There were 170 dead bodies. Most of these would be disposed of without identification. Dr Sathananthan remembered a module he studied in medical college about disaster management, which said that in mass tragedy all the corpses should be photographed for identification. He instructed me to photograph the dead. The first photograph I took was a man carrying a dead baby. Then I went to the mortuary, stood over the crowded corpses and photographed them one by one. Most of them were children. As the day before was Christmas day, many of them were dressed in their best clothes. Some had rigour mortis and had been turned on their side. Photographs for identification are useless unless they show a profile of the face; I turn the body with one hand, hold it, and photograph it with the other. This is something starkly different from the dissection room. Young people and children had signs of trauma in their face, their lives had been snatched away with great agony. My hands were trembling as I left the mortuary.

The International Committee of the Red Cross donated body bags. Immediately bodies were put in these bags and transferred to another nearby school, where they were to be kept for identification for another day before being disposed of.

As this was happening, crowds of more than a thousand anxious relatives gathered outside the hospital. Each one of them wanted to come into the hospital and search for their relative. Police were struggling to keep them out, and we feared a riot. Suddenly it happened. The police were briefly overpowered and people rushed into the hospital. There were a few minutes of chaos as the masses started walking through wards looking for their relatives. Doctors and nurses stood back helpless. A few minutes later, the local police established control again, preventing further influx, while the people who were already inside were slowly evicted.

By the end of the day there was an uneasy calm. Most doctors and medical students who had been working hard, neglecting meals or rest, slowly headed towards our quarters with fatigued faces. We heard that the tidal waves are called tsunamis, a word totally unfamiliar to the local people. We left the hospital full of people struck with grief and disbelief.

DERMOT TATLOW/PANOS

The days after

In the days to come the hospital got more organised. I was asked to contact the media and let them know of the tragedy happening there. There were very few inter-national media reporters inside the Tamil Tiger area, and we feared that the region might be neglected completely and that aid would not arrive. A census was taken of all the patients inside the hospital and in the nearby school and the names were printed and posted outside the hospital, easing the anxiety of relatives. All the photographs were uploaded into a hospital computer and were shown as a slide show. Many of the dead were identified this way. One of the unidentified children that I photographed went missing and his fate is still unknown. The rest were taken into care by the Tamil Tigers and were reunited with their families. We set up a website (www.kilimedical.com), with the photographs of the dead and name lists of the injured, transferred, and discharged patients, as well as highlighting the urgent needs of the hospital. This was to ease up the congestion of the hospital's only telephone line from calls of anxious relatives abroad and to get some urgently required items.

Bala Karunakaran medical student, Guy's Kings' and St Thomas' School of Medicine, London
Email: balamuruhan@yahoo.com

studentBMJ 2005;13:45-88 February ISSN 0966-6494

Responses published this month

Articles	Responses
LIFE The eye of the storm Bala Karunakaran (February 2005)	Dr Shyamala Hande (January 30, 2005) Read this response

LIFE The eye of the storm Bala Karunakaran (February 2005)	Dr.Riddhi Doshi (January 31, 2005) Read this response

LIFE The eye of the storm Bala Karunakaran (February 2005)	Kanchan Sharma (February 05, 2005) Read this response

	LIFE The eye of the storm Bala Karunakaran (February 2005)
	Dr Shyamala Hande (January 30, 2005) Assoc. Prof., Dept of Biology, MMMC, Manipal Campus, Manipal-576104shyamalahande@yahoo.com
	"The eye of the storm" is heartbreaking. The pain and agony of fellow human beings in the midst of such a disaster goes beyond our comprehension. High regards to the medical students , doctors , and support staff who forgetting food and sleep , worked hard for the grief stricken survivors. Watching the whole episode on TV itself was horror. It must have been a terrible thing to be amongst the heap of corpses and take pictures. The website kilimedical.com that has come up in connection with this disaster has a lot of images, mostly that of children , which are painful .The destiny of orphaned children and shocked adults separated from their loved ones will remain in our minds for a long time. Bala Karunakaran has nicely explained how each one can do your part during the time of a catastrophe as massive as the tsunami.

	LIFE The eye of the storm Bala Karunakaran (February 2005)
	Dr.Riddhi Doshi (January 31, 2005) intern, Lokmanya Tilak Municipal Hospital,Mumbai. zip code-400022 pearlevans765@hotmail.com
	The tsunami was indeed the wrath of God..It has proved to us that even in the age of technology,man is merely a small speck on the face of earth whom the waves can wash away.... I would say Bala Muruhan is really blessed to have been at that place to help the people....There are so many of us medical professionals who are feeling the urge to do something for the tsunami affected people...If I get a chance to work like Bala it will be like putting this life and education to use....It will be like I have fulfilled the purpose I was born for. But then again its not just the tsunami affected that need help.There are many places in the world which are crying out for both medical and humane efforts.Its high time,we, members of this noble profession open our eyes to the need of the underdeveloped world and quit our steadfast career oriented aims and follow the hippocratic oath in a true sense...

	LIFE The eye of the storm Bala Karunakaran (February 2005)
	Kanchan Sharma (February 05, 2005) Final year MBBS, Guys, kings and St Thomas's school of medicinekanchan.sharma@kcl.ac.uk
	Dear Editor, Bala has descriped the immediate aftermath of the disaster but what does the future hold for the victims of this tsunami? Having visited Klinochchi Hospital only 3 days after Bala had left, i found myself viewing a different picture. There were no dead bodies in open view, the crowding on the wards was greatly reduced and there was little for the medical team i was travelling with, to do. The mood in the hospital was sombre, an expression of controlled grief or guilt, at having survived. The problem was not being able to discharge patients but having a place for people to go once discharged. There was an abindance of children and women who had lost all their family, their home and their sense of belonging. I could only wonder as to what would lie as their fate. There has currently been a 2 year peace period in the civil war between the Tamil and Sinhalese people. It seems now could be an ideal time for the Tamil Tiger army to recruit orphaned children whose uneducated, impressionable, young minds are ripe for the picking. These children are destined for a hard life unless interventions are put in place to protect and provide for them. Through oppression comes progression and for this nation to move forward the Sinhalese and Tamils should work together for the good of each other.