Thailand
Soranit Siltharm, Piyasakol Sakolsattayadorn, Krit Potisuwan, and Darin Lohsiriwat, Department of
Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University Thailand
The earthquake and tsunami disaster at 8 am on December 26, 2004. killed as many as 5000 in Thailand,
with 8000 injured. A team of surgeons from the Department of Surgery, Faculty of Medicine, Siriraj
Hospital, Mahidol University, Thailand went to Taguapa Hospital Pang Nga Province, Thailand on
December 27, 2004 to help many patients. We arrived at the hospital around 5 pm, 33 hours after the
disaster. About 200 admitted patients were admitted with contusions, lacerated abrasions, punctured
wounds, most of them on the lower extremities. The wounds had mostly become infected since it was 33
hours from the injury time, had a bad smell (like anaerobic infection), pus collection, and oedema on
effected sites.
We planned to save the lives of as many patients as possible by debridement of the infected
wounds. When we opened the wounds we found pus collection, cellulitis, and fasciitis around the wound.
The culture of pus was E Coli.
On 27/28 Dec, we operated on 130 patients in 24 hours. Afterwards, the patients felt better and
fever went down. On Dec 28, 100 patients were sent to Bangkok for better and further treatment.
Anak Iamaroon and Suttichai Krisanaprakornkit, Department of Odontology and Oral Pathology,
Faculty of Dentistry, Chiang Mai University, Chiang Mai 50200 Thailand.
Amidst the daily terrorist attacks by the separatists in the three most southern provinces of Thailand, people
who live in the six southern provinces along the coastline of Andaman Sea have encountered another
tragedy, the worst natural disaster ever seen [in Thailand]. Although the tidal wave was gigantic and has
claimed thousands of lives, Thais have witnessed unceasingly pouring spirits to help badly affected tsunami
victims via all TV stations all day long. The assistance from Thais as well as many other countries might be
the biggest aid we have seen in our lives. A great deal of complimentary from foreign survivors has been
granted to Thais for their kindness and hospitalities.
Health personnel in every field from both government and private-owned hospitals have been
responsible for treating injured Thai and foreigner victims. The badly injured victims were transferred to
many private-owned hospitals in Bangkok by the C130 airplanes of the Thai Royal Air Force. In our
opinion, the issues of relief efforts and the medical supplies in Thailand are adequate for those who need.
In fact, the Thai government has donated some money and other forms of assistance to other neighboring
countries that were also affected by this Tsunami. Although we can deal with the injured and survivors very
well, we are facing with the new problem we have never before seen, i.e. to identify a large number of dead
bodies at the same time in this chaotic situation. With the international assistance from several forensic
teams, everything is getting organized and this problem is now being solved. However, from the lesson of
this disaster, we have to very much improve all involved Thai organizations dealing with the early warning
system, the management of relief efforts for the victims, and the Forensic Medicine and Dentistry.
As part of the health professional community, we as dentists can help identify the dead bodies by
conducting dental examination, X-rays, dental impressions, and pulling some teeth out from the corpses for
later DNA extraction and fingerprint. In fact, there are so many dentists (more than 100) as representatives
of the Thai Dental Council and all eight dental schools in Thailand working in the disaster areas right now.
Hopefully, all kinds of joint efforts from everyone in this country will bring the situation and lives of the
people in the disaster areas back to normal very soon.
At first, we were very much worried about an outbreak of infectious diseases, like respiratory and
GI infections due to the poor sanitation in the disaster areas. However, we have seen only few cases
reported by the Ministry of Public Health so far. It seems to us that the psychological problems of Tsunami
victims are far more worried than the physical problems. Many children have been left as orphans without
their parents or relatives in their families, or several parents have lost some or even all of their own
children. Hundred thousands of people have been left homeless and jobless. These psychosocial problems
are far more serious than anyone could imagine and need to take a very long time to cure. The Thai
government has done its best to proceed with the rehabilitation schemes for the victims, such as getting
clean water, foods, and medicine for much needed victims, constructing a large number of temporary
shelters and new houses, repairing boats (because many of the victims are fishermen), issuing several tax
relief measures, soft loan packages from the Bank of Thailand worth Baht30 billion, etc. The psychiatrists
and psychologists from every Thai psychological institution have now taken turns to untiringly help victims
through this difficult period.
Pipat Luksamijarulkul, Assoc.Prof. Faculty of Public Health, Mahidol University
Our Ministry of Public Heath has issued a health warning to prevent some health problems of which could
occur including diarrhoeal diseases, hepatitis A, respiratory infections, arthropod-borne diseases,
conjunctivitis and infected wounds. In addition, the health activities, such as, basic sanitation, vector
control and stress reduction have been emphasized in the critical areas (tsunami-effect areas). I thank that
the buffer zone or areas surrounding the critical areas (about 5 Km far from Tsunami-effect areas ) should
be done for epidemiological surveillance of important diseases including food/water-borne infections and
vector-borne diseases due to the population movement and the changing of ecology. Good prevention
measures should be extended to the buffer zone not only in the Tsunami-effect zone. Next week, our
faculty (Faculty of Public Health, Mahidol University) will set at least 2 or 3 teams to do the rapid survey
and need assessment towards health interventions and epi. surveillance. At this time, I have no details. On
Thursday (13th Jan), our faculty team will go to do the rapid survey and need assessment, after that, we will
have a meeting to set the health activities. However, in our plan, we have 3 teams as follows; 1. The
environmental health team consisting 3-6 researchers, 2. the health promotion team consisting 3-6
researchers, and 3. the infectious disease and epi. surveillance team consisting 3-6 researchers ( I am in the
third team). Our dean, Assoc. Prof.Dr Chalermchai will be the head of the teams.
Viroj Wiwanitkit, Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand.
This is the first episode of disaster resulted from earthquake in Thailand. Also, it is the biggest natural
disaster in the Thai history. Most of Thai medical workers lack for the experience on pre-hospital and
disaster medicine to this episode. However, all physicians in the area as well as those from distant countries
well collaborated to face up with the situation. Most identified medical problems of the Tsunami victims
were downing and physical injuries. As previously mentioned, there were limited medical resources for the
disaster management at first. However, with the collaboration of Thais and international help, the situation
could be effectively managed. On 7 January 2005, there are still nearly one hundred of patients admitted to
the intensive care units of many hospitals with the problems of fracture and pleural effusions. In addition,
much more patients are hospitalized with several less severe medical conditions.
At first, there was a large demand for blood and blood product for the patients. The blood
requirement reached the peak in the first three days after the disaster. During the period between 27
December, 2004, and 3 January, 2005, 20,682 units of blood were collected (1,409 units from foreigners
and total Rh-negative equal to 332 units).
At present (7 January 2005), the big problem is not how to manage the injury but to manage the
remaining death bodies in the attacked areas. Continuous attempts have been used to find the bodies
including a batch of elephants to help search for remaining bodies or missing ones in some sites being nonaccessible by human rescue teams. The identification of the death bodies is a very big problem. Indeed,
there are fewer than fifty forensic physicians in Thailand, therefore, it is totally insufficient to cope with a
big catastrophe like Tsunami. Luckily, a number of Thai volunteers came to the site to help some basic
works. Call for help to many countries was done and a lot of help came into the site. Several technologies
including DNA collection and microchip are applied to the deformed and unidentified death bodies. The
infectious control of death bodies is also well performed.
In the view of medicine, several effects of the disaster on Thai medical community are noted. All
physicians worked hard to cope with the medical problems of the victims. The power of the collaboration
among physicians, both Thai and foreigners, is very impressive.
The Thai medical community can learn a lot from this disaster. The review of medical response as
a relief effort to the disaster is needed. The most important point is to set the more effective preventive
medicine to the disaster. The medical education on disaster medicine is required in order to avoid the
improper medical management. The preparing for the medical supplies for the future possible disaster such
as the site operation room should be done. To increase the communication skill to the foreigner and
knowledge on travelling medicine should be promoted. The review on the national policies on the public
health management in disaster should be performed. The multidisciplinary approach, joining all workers
from several careers, is recommended. Sharing of experience and international collaboration is also
recommended.
Chirayu Udomsakdi Auewarakul, Faculty of Medicine Siriraj Hospital, Dept of Medicine, 2 Prannok
Rd, Bangkoknoi, Bangkok 10700, Thailand.
I am an Associate Professor at Faculty of Medicine Siriraj Hospital, Bangkok, Thailand. I trained at Duke
and Harvard. We Thais all suffered from the Tsunami. I lost my friend who was walking on one of the
beaches at the time the Tsunami hit. He had a son who is still in kindergarden. Our king lost his grandson
also. We felt sorry for the tourists who lost their lives in our country and the government had tried their best
to help everyone.
Currently, the system in Thailand is quite efficient and the Thai government has issued many
immediate and long-term plans to help the people and the environment. There are not epidemics of any
diseases at the moment. But the most important trauma is the psychological trauma. The government has
also sent hundred of psychiatrists to the south to help the people.
Manat Panamonta, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Thailand
I would like to share my thoughts and experiences with you and other colleagues. I have many colleagues
have been working in the relief effort in Southern Thailand. In the first 2 days after the Tsunami, there were
severe deficiencies in surgeons, orthopaedists, physicians, nurses, blood (i.e. Rh-negative blood), rubber
gloves, drinking water and food. Later, deficiencies in forensic identifications and management of dead
persons have arisen. The diseases or injuries initially were related to trauma but later the complications
related to trauma like wound infections have arisen. Psychiatric problems of affected persons have been
prevalent. This event has affected not only injuries or diseases to the victims but also the family structures
of the community (many orphan children) in these countries. Thank you very much for your attention to
this disaster.
Kittipong Dhanuthai, Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn
University, Bangkok, Thailand.
I and my colleagues as dentists went to work in the affected area to identify the dead bodies. What we did
was to inspect the teeth: the positions as well as types of filling material, position of missing teeth and type
of occlusion. The first step was to thoroughly examine the teeth. The second step was to do the bite-wing
on both sides. We had 4 mobile x-ray units at that time. We had to use a metal tube to press under the chin
to put the mouth close together. We had to move the dead bodies to the x-ray setting. We still lack the lead
apron for x-ray protection. The last step was to pull out a tooth for DNA extraction from the dental pulp.
There are many teams, but I and my colleagues were from Chulalongkorn University. We took the x-ray of
the teeth. These information when compared with the dental records can help identify the deceased person.
Immediately after the tsunami disaster, we lacked all kinds of medical supplies and blood
especially Rh-negative group because we did not prepare for the huge number of casualties like this. We do
not need medical supplies after the mobilization of both the medical supplies as well as medical personnel
from across the country to the affected areas. We still need disinfectants for the prevention of the epidemic
outbreak.
Since a lot of children lost their parents in the tsunami disaster, there is a scarcity of milk.
Numerous survivors from this disaster lost their properties and love ones and are in the state of shock and
grief. They need psychiatric counselling.
So far, there has been no outbreak of infectious disease such as typhoid or cholera reported.
This incidence help prepare our medical staff for a natural disaster or war of this magnitude.
Jessada Chungpaibulpatana, Director of Vachira Phuket Hospital, Phuket and Somnuek
Domrongkitchaiporn, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok
There were 863 victims from Tsunami, 431 Thais and 432 foreigners, admitted to the hospital. Forty- four
victims died after admission and 138 required major operations. Most patients suffered from laceration,
compound fractures, aspiration pneumonia. Most wounds were contaminated and contained foreign body,
mostly sand. The causes of dead were ARDS, severe pneumonia, septic shock from severe fasciitis.
Aeromonas spp. was one of the most common organisms involved in severe sepsis. Those who survived
from near downing also suffered from sand packing in their nose, ears, and oral cavity.
As expected, the medical aids were insufficient. Inappropriate wound cares resulted in severe
sepsis, for example tried to suture contaminated wounds. The whole nation has never prepared to deal with
such a great disaster in our history. However, very impressive contributions from all the people and all
organizations, without asking, to help the victims are very helpful. There is no outbreak of diarrhea
subsequently as clean water and food were supplied to the areas immediately.
Chansak Wacharong and Bovornrit Chukpaiwong from Takuapa Hospital, Phung-Nga province;
Banchong Mahaisavariya from Faculty of Medicine Siriraj Hospital, Bangkok Thailand 10700
On 26 December 2004 in the morning the Tsunami had attacked the western coast of the southern part of
Thailand. These included Phuket, Phang Nga, Krabi, Chumporn, Trang and Ranong provinces. There were
6-8 huge waves of more than 5-7 meters threw over the beach of those 6 provinces. The tsunamis destroyed
almost everything along the beach of more than 300 meters far from the ordinary sea shore level. The
victims included all people on the land and also inside the vehicles on the road close to the sea shore area.
Tsunami victims were injured by the wave containing several things including stones, pieces of wood from
trees, pieces of concrete or broken glass or metal from buildings which were destroyed along its path. Most
of the injured parts were those of under the water. The lower limb was injured more often than the upper
limb. Most of the survivors were minimal to moderately injuries to body and extremities. The dead victims
were those who were drowning, being entrapped inside the destroyed building, thrown over cars etc.
Takuapa hospital of Phang Nga province was the most severely attacked by Tsunami and two of
the authors (CW ,BC) were working there after the disaster. The hospital was located 3 km from coast that
was attacked by Tsunami. There were more than one thousand patients attended the emergency room
during first 24 hours after the disaster. Takuapa hospital is a general hospital that has 180 beds. There are
only 10 doctors including; 5 GP, 2 orthopedists, 1 surgeon and 2 pediatricians. All were called to take care
of patients at emergency room as for mass casualty event. The hospital could accommodate only 50 to 60
casualties. Because of the huge number of patients were admitted to the hospital of more than 500 patients
within 3 hours after injury. All doctors were joining at the emergency room to help in first aid management,
resuscitated and identified the patients that required surgical debridement. The communication via
telephone was not possible for several hours after Tsunami. Some of severely injured patients were
transferred to nearby provincial hospital. The need for help was directly informed by the hospital
ambulance drivers to medical staff of the provincial hospital at the time they reached the hospital. Several
ambulances and medical personnel from provincial hospital were then sent to Takuapa hospital to assist for
the task. In the first day after the Tsunami attacked, patients were admitted to the hospital more than
thousand. Half of them need hospitalization. Because there were only 4 operating theaters the patients were
unable to be operated within golden period. Almost all wound were treated lately which gradually became
infected. Some of severely injured patients were transferred to other provincial hospitals. In the morning of
27th December there were medical team physician and many organizations from Bangkok (including the
author BC) came to assist for this task. Many tourists who were injured were transferred to Bangkok.
Almost 200 patients who needed emergency surgical interventions were still being treated at Takuapa
hospital. There were 60 severely injured patients which mostly were transferred to the other provincial
hospitals. Most of these patients had open fractures of the long bones either upper or lower limbs. Almost
140 cases that need surgical intervention had infected wounds. The wound has it specific characteristic.
There were multiple small to medium wounds along the head, face and extremities. The location of the
wound was more often on posterior aspect of head, back, buttock and legs. The wound was severely
contaminated, grayish wound, sand like contamination and foul-smelled. Some wound had only small
opening tract but inside are cavity that contain lots of contaminants such as sand soil and wooden stick.
During debridement it was usually found extensive fat necrosis above and below the fascia of the muscle
with Grayish sand-like contamination. Most of them extended more than 5 times of the initial size of
wound. Almost all the wounds that seem to be adequately debrided and were sutured in the first day were
infected and need re-debridement and the wound was left open for drainage. One-third of cases needed redebridement due to further tissue necrosis.
One of the most serious and massive extension of infection are occur with the wound at posteromedial
aspect of the knee. There were only 3-5 open fractures that were treated at Takuapa hospital. The fracture
were not securely fixed with any implant because of the serious contamination of the wound (open fracture
of distal humerus, hand, distal tibia and femur)
Most of the patients especially the tourists from foreign countries who received proper initial
medical and surgical treatment were referred to hospital in Bangkok to received further treatment or
referred to their home country. The infective organisms that were identified in later stage were mostly
multi-organisms including: gram negative, Klebsiella and E coli. In patients with severely injured limbs,
the infection was difficult to control required amputation in later stage.
There were several problems in the orthopaedic trauma patient care after Tsunami attack including: too
many patients to be accommodated by either single hospital or even several local hospitals; communication
failure usually happen and will compromise for co-operation among hospitals; medical personnel, medical
equipments and the operating room are not adequate to serve the huge number of patients; wounds and
open fractures being treated late and become infected in almost all cases; the wounding mechanisms was
found special characteristic with highly contaminated; the organisms were found mostly: gram negative, Ecoli, Klebsiella.
The most important treatment in tsunami injury is a well-formed team that can give rapid initial
treatment for large number of patients. Wound from this kind of injury is severely contaminated so
adequate debridement and delayed suture are recommended for all of the tsunami-injured patients.
Antibiotics and tetanus prophylaxis must be administered to all patients who have wounds.