Bali Bombings: Royal Perth Hospital heroes reflect on remarkable response after terror stuck

‘DIRTY’ BOMB SENT CHILLS THROUGH DOCTORS Faced with the ravages of a “dirty bomb” from Bali, an extraordinary response from WA’s medical services was ignited in a coordinated operation never seen before — and arguably not since. Royal Perth Hospital clinical services executive director Bill Beresford has reflected on the remarkable and united operation from staff across many medical facilities — and from the community — to mark the 20th anniversary of the devastating Bali bombings of 2002 that killed 202 people, including 88 Australians. But three days into the mission, he said the dynamic was heightened when it became clear the bombs had been deliberately packed with bovine excrement to guarantee maximum devastation through contaminated wounds for those who survived the blasts — significantly increasing their chances of death. “We didn’t expect it to be a dirty bomb, that had a big impact on us,” Dr Beresford said. “No matter how infection control tried . . . the people were coming in with all different diseases. We knew there would be contamination and infection anyway, but this was shocking.” And as the searching requirements piled up, bold leadership was needed. “I never obeyed rules,” Dr Beresford, the metropolitan disaster coordinator, said bluntly. “If things are needed to be done, you do them and pick up the consequences later. It’s why I was never popular with the politicians. Some rules had to be sidestepped.” It was a difficult first 48 hours for the medical staff as they awaited the influx of patients. Dr Beresford had started assembling the team just a few hours after the blasts on what was otherwise destined to be a lazy Sunday morning. Royal Perth Hospital was Perth’s biggest teaching hospital and had 855 beds on two campuses. It was also Australia’s second-busiest trauma hospital and emergency department, but only had a maximum 17 beds in the burns unit. And staff desperately tried to make up for lost time with patients because of the many medical insufficiencies while they were still in Bali. All elective surgery was cancelled and the intensive care unit was cleared to make room for 30 ventilated beds. Triage teams were sent to Perth Airport to help streamline the initial treatment process and Dr Beresford, who had liaised with the Federal Government’s Emergency Management Australia agency, said communication was paramount at all levels. The 28 patients rushed to RPH had burns to their bodies ranging from two per cent to 93 per cent. There were also many blast and inhalation injuries, perforated eardrums and psychological trauma. Three theatres worked simultaneously with up to 12 surgeons and 28 nurses at a time. There were three deaths. Dr Beresford said the generous decision by Seven West Media boss Kerry Stokes to send his private Lear jet on a mercy dash to help get patients back to Perth quickly for treatment had been pivotal. It brought the first load of passengers, including 11 surviving members of the Kingsley Football Club, just 27 hours after the blasts. “There is no doubt that jet helped save a lot of lives,” he said. A pre-testing a year earlier of the State Burns Plan, led by Dr Fiona Wood at an oil rig off Karratha, had readied the medical services that would become crucial in the response. Dr Beresford had previously recruited Dr Wood into her burns specialty and he described her as a “natural leader and innovator”. But he said he remained proud of the investment to help by a great many West Australians. “It was a metropolitan-wide response . . . you’d almost call it a Battle of Britain spirit,” he said. “This hospital had an ethos of service. People were volunteering to come in on their days off to help out and responded not just in this hospital, but all hospitals and it was truly amazing how they responded. “Even the way the community got around it — people were volunteering to donate blood, sending flowers, coming in to interpret for some of the patients and providing food for the staff. They went out of their way to respond and give support, you can’t measure it and you can’t cost it. “It was all much more than I expected and you realised you couldn’t have done it without them. It increased the level of pride in people throughout the health system and showed the people of WA that we were able to respond to a disaster.” Dr Beresford had been in WA since 1979 and used part of his time working with the Royal Flying Doctor Service in the Kimberley to develop disaster planning. Later, as Health Department medical services director, he drew up disaster plans for every hospital in the State. In October, 2002, it would prove vital. He said one of the most satisfying results from the response was having a National Burns Plan fast-tracked. Current RPH boss Lesley Bennett said she was confident the facility would again rise to the challenge of another major disaster if required. “Absolutely confident, especially now we have all our beds open at Royal Perth and the hospital is back to the size it was before Fiona Stanley Hospital opened,” Dr Bennett said. “Our staff have demonstrated through the COVID pandemic that they are flexible and resilient. We have a team of clinicians throughout the hospital who are experts in trauma management and importantly, have many years of experience working together as a team. “We also have systems in place that enable early, hospital-wide activation that quickly brings critical team members together to ensure a state of readiness in the hospital.” POWER OF POSITIVE PEOPLE HELPED ME GET THROUGH Bali bombings hero Fiona Wood believes recognising the extraordinary medical work done for victims of the blasts has helped heal the physical and mental pain from the attack — even her own. Professor Wood has been roundly praised for her role in leading Royal Perth Hospital’s indefatigable burns specialist team, which was suddenly inundated with patients suffering a range of significant injuries from the mass disaster. And while no training could have completely prepared them for that work, they united behind a “robust disaster plan” and a dedicated spirit that would not allow them to let their fellow humans down. “There is a team of people that, for whatever reason, we’re focused and passionate about making sure that we reduce the suffering from burns injury day-in, day, out,” she told 7News Perth. “And then something like this happens and you realise the extreme nature of it. But to be honest, I saw so much positivity in the team and in the people around us, (and) in the community. It was the time that changed me because I realised there were an awful lot more good news stories and we need to share them. And on a personal level, I found that it’s not a weakness to ask for help.” Professor Wood and her team spent many weeks performing surgery and caring for 28 injured patients with between 2 and 93 per cent body burns, deadly infections and delayed shock. She recalled how there had to be an “exquisite” attention to infection control once it was realised they were dealing with wounds caused by a “dirty” bomb. They worked in deliberately set 32C heat in the theatres to ensure patients were kept at the right temperature to deal with their injuries They also made a promise to treat each patient as an individual, not as a group of victims. Professor Wood said the lessons of the effort had left a great medical legacy. “I think 20 years has gone in a blink,” she said. “It is a significant period of time and we’ve been able to do a lot in that time with research and trying to change people’s lives. We’ve still got a long way to go, but it’s a time to reflect, I think.” SERIOUS SHRAPNEL WOUNDS Memories of the deep wounds filled with dirt and shrapnel, most of them surrounded by horrific burns, are still vivid for plastic surgeon James Savundra. Just two years into a now long-term Royal Perth Hospital tenure as a specialist, Dr Savundra has for the first time detailed his role in the team that cared for what seemed to be a never-ending line of patients from the Bali bombings of 2002. RPH’s only remaining plastic surgeon from that time, Dr Savundra admitted the medical team had been unfamiliar with large-scale bombing injuries. But they united from several facilities across Perth to help the mission’s two burns surgeons, Fiona Wood and Mark Duncan-Smith, and even included pediatric surgeons from Perth Children’s Hospital. A pod of seven theatres was staffed around the clock and about half of the intensive care unit was dedicated to the disaster. And the work was confronting. “Some of them might have had 10 lacerations on their body with deep wounds and dirt and shrapnel in the base of those wounds, along with burns on the outside,” Dr Savundra recalled. “The surgery involved cleaning the wounds, removing the shrapnel, repairing the wounds and then also dealing with the burnt skin . . . they were big injuries. Some of the wounds also went into muscles, so some of those patients required significant rehabilitation. And the shrapnel injuries were being managed primarily by plastic surgery, just to relieve the pressure from the burns. “By the time you finish your training as a plastic surgeon, you’re pretty much prepared for some serious and devastating injuries. But the volume of patients felt unending and I can’t really remember anything similar, before, or since then. Dr Savundra had been the on-call plastic surgeon at RPH alongside Dr Duncan-Smith when calls started coming in warning of the potential fallout from the catastrophic event. One of the calls was from RPH registrar Vijith Vijayasekaran in Bali, giving the local team a trusted and informative link on the ground. Dr Vijayasekaran had been holidaying in Bali with his anaesthetist wife Priya Thalayasingam. Soon, it was mayhem in the RPH corridors. “It took us a couple of days to really realise how many (patients) there were,” he said. “But once they started coming, it was all hands on deck. “Our junior doctors were under the pump so our specialists had to do a lot more work than we would normally do in a week on call. But by the time we knew the numbers, we mobilised a lot of facilities in this hospital. “We were used to doing big and long hours, but there is not really any such thing as safe working hours when that sort of thing happens. We basically put off what we could and did what we needed to do urgently.” Dr Savundra said the commanding leadership of then-hospital boss Bill Beresford was crucial in the response. RPH’s cardiac surgeons diverted work to other medical facilities to open up more theatre space and intensive care unit beds at RPH for the Bali victims. Sir Charles Gairdner Hospital and Fremantle Hospital took several other patients with more minor injuries from the bombings to further ease the pressure on the central response facility. “I tell you, it just ran like clockwork,” Dr Savundra, a former Australian Society of Plastic Surgeons president, said. “Basically, surgeons came from other hospitals to help and we just worked through all the patients over two or three weeks. It was amazing how smoothly things ran to get the facilities we needed to manage such a large number of patients. “There was State-wide camaraderie. Everyone came to the party and RPH found the facilities to do what we needed to do. It was a good chance for many practitioners from many sites to come and help out, and there wouldn’t be many hospitals in the world where that sort of thing would happen.” SOME SURVIVORS QUESTIONED THE WHOLE MEANING OF LIFE The mental wounds left by the Bali bombings were in many cases more enduring than the physical injuries that have long since healed. And it was likely the contrast of having an idyllic, laid-back holiday at a tourist hotspot renowned for its peacefulness and partying, suddenly broken by terror that created the scars others could not see. “These were ordinary Australian people who went to Bali for a holiday, to celebrate life and relax and unwind . . . they thought it was safe,” Royal Perth Hospital psychiatric consultant Nigel Armstrong said. “But to have that experience suddenly shattered, was a shock.” Dr Armstrong had been working as a full-time psychiatric consultant at RPH for only two years when he was faced with a searching test of his training. He remembered then-medical director Bill Beresford calling a snap meeting of all department heads in the executive board room as the magnitude of the bombings and resulting injuries started to filter through. And among the many patients who needed emotional help in their ordeal, one of them has remained in Dr Armstrong’s thoughts more than most. “Some people had a grief reaction because they’d lost a loved one,” he said. “I remember one of them had a fiance who had just died and was in a state of grief. The last thing we wanted to do was pathologise that. “She’d found the love of her life, gone to Bali and they were sitting at the bar and he died. Suddenly, what was the meaning of life? Some patients were asking these ultimate questions. “Sometimes in life something bad happens to us and sometimes we will say it is so bad, what is the point of being here? If you think and feel like that, you are a victim of the trauma. “So the question for us was, what can we do to them to be a survivor of this as opposed to feeling a victim of it?” It was the first time Dr Armstrong, and many of his colleagues, were called to respond to a major disaster. But despite the issues of acute stress, anxiety, nightmares and depression unfolding before them, they were also cognisant of the fact that some patients just needed time and space to reconstitute their defences. “It’s not one-size-fits-all,” he said. “So at all levels, we tried to supply the support so that no one fell through the cracks.” Even then, it was still difficult to assign treatment to patients whose emotions were changing with each passing period of time., despite the obvious relief at having returned to Australia. “They felt unsafe in Bali and suddenly they felt safe at home again,” Dr Armstrong explained. “Australia said, ‘The nation is going to take care of you’ and immediately, they weren’t alone. Some of them were desperate to get out and be with their families and loved ones, but some of them didn’t realise the significance of what had happened to them. “I don’t have the statistics, but I would imagine there were some people for whom this event scarred their lives.” Dr Armstrong said he once had the chance to move his service to the new Fiona Stanley Hospital, but the feeling of connection at RPH built through the camaraderie during the Bali bombings response had prompted him to stay. VOLUNTEERS AT ALL HOURS Doctors from Royal Perth Hospital had been enjoying a springtime social function when news bulletins about bomb blasts in Bali first began filtering through. Leigh Combes, the then-head of RPH’s department of anaesthesia and pain medicine who was hosting the function at his home, said while details about victims of the bombings were sketchy at first, the news rang alarm bells. “This event in Bali seemed to have all the hallmarks of trouble for us,” Dr Combes said. “Firstly, they were westerners, and there seemed to be a lot of them. “At the time we were not only the trauma hospital, we also hosted the burns unit. We kept our ears on the radio and started making a few phone calls.” As the day wore on, the doctors began to realise the scale of the disaster, but their role was still unclear. Then they learnt that a flight from Bali to Perth would be carrying some of the most severely injured blast victims. Dr Combes set up four teams of specialists who all volunteered to front up to the emergency department in the middle of the night to wait for the patients to arrive. “When they arrived they were in terrible condition,” he said. “Burn injury is a terrible injury — and they were very extensively burned.” After the specialist teams intubated the patients and began resuscitation, they took them straight to a surgical theatre to scrub and debride their wounds, and then to intensive care. “That really started for us weeks and months of work, as more waves of patients arrived and the first patients would come back to theatre for the second stage of their procedure,” Dr Combes said. “And so it would go on, wave after wave of surgical interventions on these patients.” Medicos at WA’s leading trauma hospital were accustomed to dealing with severe injuries and pain, but the number of burns victims was on a scale they had not seen before. While a patient could be severely burnt and still be conscious, they were unlikely to survive if left untreated for more than 24 hours. “We were now seeing them at over 24 hours, so we were really concerned that we were going to have these patients maybe past the point of reversibility,” he said. As Dr Combes had predicted on that sunny spring afternoon, RPH played a central role in treating those injured in the bombings which killed 202 people, including 88 Australians. Thirty-one victims were treated at RPH, eight of whom required intensive care. Three patients died from their injuries. Dr Combes said the tragedy had reinforced for him the professional dedication of his staff. “It was a straightforward matter to get my volunteers to be there in the middle of the night — consultants, registrars and technicians — they weren’t on duty, they just came in because we asked them to and because the circumstances demanded it.” RPH pain management consultant John Akers echoed his sentiments. “There was a great camaraderie and sense of common purpose,” he said. “We all got a lot of important teaching in dealing with burns patients.” The scale of the emergency prompted innovative reforms to patient care and pain relief. “We tried to introduce techniques which could be used on the ward and in the burns unit, which were intensive mechanisms of giving the patients analgesia, without them necessarily having anaesthetic every time,” Dr Akers said. The approach allowed patients to deliver a dose of pain medication to themselves during the long and agonising process of having their dressings changed. While both doctors spoke of the need to distance themselves from emotion when focused on a patient’s treatment, Dr Combes’ eyes welled with tears as he reflected on the tragedy 20 years later. “The Bali bombers sought to advance their agenda by murdering and maiming as many people as possible — that’s the very anathema of health care and our professional life’s mission,” he said. “While our every effort was focused on the patient directly under our care, in the operating theatre or the ward, our unspoken goal was also to take back the bodies and the lives from those bombers’ murderous intent. “To save life and to restore health through our calm commitment to our professional roles, to defy the terrorists. To win those battles, and to have our patients survive.” To commemorate the key role RPH played in caring for victims of the Bali bombings, WA Museum Boola Bardip will display a special exhibition of images from October 12. Remembering the Bali Bombings 20 Years On pays tribute to the extraordinary efforts of hospital staff during that time.