The day after the Bali bombings, burns specialist Prof Fiona Wood made a 'courageous' decision.

The following is an excerpt from Under Her Skin by Sue Williams, the remarkable story of Professor Fiona Wood AM whose groundbreaking research and technology development has changed the lives of burns patients.

It was the biggest ever peacetime emergency evacuation of Australians from overseas, and the largest air evacuation since the Vietnam War, with more than 100 patients—most with horrendous burns and terrible injuries, and many fighting for their very lives—airlifted to safety.

But what made the biggest impression on Fiona that day was something much more intimate. ‘The thing that overwhelmed me when I saw the patients was the look of relief on their faces,’ she says quietly. ‘That’s the one image I’ll remember forever. They were home: they felt safe; they felt secure. But we knew their battles had only just begun, and we got straight to work.’

With most foreigners now being extracted, Sanglah Hospital and clinics in the neighbouring areas were better able to cope with the smaller number of Indonesian casualties. Meanwhile, eleven patients arrived in Perth direct from Bali, among them 29-year-old Sydneysider Jodie O’Shea, the young woman Dr Vij Vijayasekaran had been so impressed with. Her burns had, back then, looked the most severe at 92 per cent, but her demeanour, her humour and her obvious courage had made Vij hope against hope that she’d be able to beat the odds. On her arrival in Perth, everyone immediately understood why. The emergency staff were all similarly charmed by her smiles, her polite manner and her grace, and were devastated to realise she was unlikely to make it; her injuries were just too overwhelming. But when she died within a few hours, it was, at least, in her mother’s arms.

Two other critically ill women also came in that first contingent to Fiona’s burns unit. Perth mum Tracy Thomas, 41, had been holidaying with a friend when they ducked into the Sari Club for a drink. She’d sustained burns to 60 per cent of her body, severe blast injuries and terrible shrapnel wounds. Her three daughters, Carla, Kimberley and Lauren, had rushed to be by her side while the doctors assessed her, stabilised her and decided what to do next. Then there was Simone Hanley, 28, with 75 per cent burns, whose kidneys had stopped functioning. She was put into an induced coma and placed on a ventilator because of the heat damage to her lungs. She’d been in Bali with a group of girlfriends and her sister, Renae Anderson, 30, who was still missing.

Thanks to the outreach project that had previously been introduced, which involved caring for people at home after their recovery from surgery, a number of existing patients could be moved out of hospital wards to free up their beds for the Bali injured. Shortly after that was done, seventeen more survivors arrived from the 61 flown direct to Darwin. That made it a total 28 patients with burns in Perth’s care, the most of any hospital and just over half of the total 52 who were critically ill with burns injuries. With vast areas of their bodies scorched and blackened, gaping shrapnel wounds, deep glass cuts, appalling blast injuries and tissue damaged by the shockwaves from the bombs, their care was a daunting task. ‘It was like working with the survivors of a war zone,’ Fiona says. ‘These were devastating, complex injuries, way beyond any injuries I’d ever seen, and had to treat, in the past.

‘But my overwhelming sentiment at that time, and even afterwards, was feeling very privileged to be in a position to be able to help. Everything I’d learnt to that point had prepared me for this. I’d had all the education and the training and done all the research and innovation that would allow me to try to help people with their life journey when everything had gone so seriously pear-shaped. I wanted desperately to help, and knew I was in a very good position to do so.’

Fiona’s team’s well-planned disaster strategy involved her coordinating four operating theatres running concurrently, nineteen surgeons and 130 other clinical staff, a program that had swung into action as soon as their patients had arrived. She oversaw the whole set-up, assisted by the hospital’s burns plastic surgeon Dr Mark Duncan-Smith, Dr Anna Goodwin-Walters and other specialists including Dr Colin Kikiros and Dr Ian Gollow from the Princess Margaret Hospital for Children.

‘We commandeered half of intensive care, and we quarantined all the patients from Bali away to protect everyone else in the hospital from any infections they might have, and in order to contain their infections,’ Fiona says. ‘I remember sitting in the boardroom on the Monday when we knew we had 28 patients and a full burns unit and we decided we still wouldn’t turn anyone away unless we couldn’t do the job. The challenge I put to everybody that day was that we needed to treat every person coming to us from Bali as if they were each an individual patient. And if we couldn’t do that, we would have to work out why, and solve the problem quickly, so we could.

‘Then one of the nurses in charge of theatres, Carmel McCormack, stood up and said we had three hours to sort out any problems, from nursing, to theatres, ICU, anaesthetics, equipment and stores. We started on Wednesday and our goal was to remove all the burns by the maximum of seven days. We got massive teams rotating through, from the Royal Perth Hospital and across the city, to make sure everyone was at the top of their game and had the operating theatres each working full bore for five days. We wanted to make sure there was no idle time as we were in a position of so much urgent need.’

Physiotherapist Dale Edgar was at that senior clinician meeting where Fiona issued her challenge of treating the patients individually. He was taken aback at first, but full of admiration.

‘I think that’s one of the most courageous things Fiona ever did, while some people might say that it was one of the most stupid things,’ he says. ‘It was in the eerie period of waiting for the casualties to arrive, and Fiona basically said that we’re going to treat these people as if they’re our normal day-to-day patients. For anyone who understands mass-casualty situations, receiving more than your yearly number of major burns patients in a day, you know, is not very conducive to treating every single patient as if they had come in one at a time.

‘But that was the commitment that Fiona gave and that’s the reason we achieved what we did in getting patients treated and out of the hospital in time frames that were either faster, or the same as, our normal practice. It worked because the whole health system and hospital essentially clicked into gear and everyone worked together. Bali was an amazing example of what can happen when people work as a team. Some people might argue that we shouldn’t have taken so many patients—the 28 and then others who came in in dribs and drabs afterwards— but we had a system that was actually amped up.’

By 5 a.m. on Monday 14 October, Fiona was at the forefront of all the surgeons operating on the patients most in need, including those two still clinging to life, Tracy Thomas and Simone Hanley. The rest of the time, she’d be discussing with other surgeons any challenges they were facing with surgery, and working out the best way forward.

McCormack’s memory of those frantic first days is still vivid. Surgeons who’d worked at the hospital over the years had flooded back into the unit, as well as those from elsewhere, and they were all asking Fiona where she wanted them. Plastic surgeons and burns surgeons from all across Perth had also turned up to volunteer their services and awaited instructions. McCormack herself had come in at 4.30 a.m. on her day off and worked straight for the next fourteen days. She organised with the storeman to gather all their supplies, and phoned all the hospitals and clinics in the area to borrow extras, as well as equipment and staff. Not one request was refused.

‘Then Fiona would say, “Great, you go to theatre two, and you go to theatre three, and I want you to go over here,”’ Cormack recalls. ‘She had a whiteboard with everything written up on it, the patients and where they were and what was happening. Then she set up whiteboards in every theatre with instructions for the surgeons on what to do. She’d talk everyone through what they should be doing, like mission control.

‘There were lots of people involved, of course, but Fiona brought the whole thing together. She said what she wanted, and everyone—however senior—just buckled down and got on with it. There were a lot of senior people there, plastic surgeons, burns surgeons, some people I hadn’t seen for years. But they all turned up like little soldiers and asked her what they could do, and she allocated each of them tasks. It was so amazing to see.’

Nurse Kim Bowen also remembers Fiona firing on all cylinders. ‘She was a rock,’ she says. ‘She just kept going. She was doing her very best for all those patients, and at the same time liaising with health ministers in the state and federal governments to get more equipment and more funding so we could service them better.’

A second triage unit was set up in the emergency depart- ment and, from there, patients were sent to the operating theatre to have their burnt and damaged tissue cleaned and removed, or debrided, and for any necessary escharotomies to help them breathe more easily and to prevent limbs having to be amputated later. They’d then receive skin grafts from any part of their body not burnt or have donor skin and their own spray-on skin. Shrapnel would be dug out from their bodies and infections and bacteria treated. The supply of blood from willing donors that was quickly tested, matched and then given to patients within four hours of it being taken—called ultra- fresh blood—gave everyone the best chance possible. Some of the operations would last more than ten hours, and various teams worked on 30 operations in a row.

Afterwards, patients would go into the intensive-care unit (ICU) for ventilation and support or to the wards. They all also had to have their fluid intake balanced via IV drips, just like Vij had done back in Bali. McCormack organised with the engineering staff to turn up the heat in all the operating theatres to that magic temperature of 32 degrees Celsius that is so necessary for burns patients, and then made sure there was food and drink on the premises so everyone could keep working.

Clinical nurse consultant Joy Fong was taken aback at how everything ran so smoothly, despite the severity of the patients’ wounds and the numbers they were having to deal with at the same time. Over a usual year, they might have ten major adult burns patients to deal with; now they had 28 all at once.

‘We had so many patients and we had to accommodate all of them,’ she says. 'We overflowed into the plastic surgical ward next door and then, at some stages, we overflowed into the medical ward, too. The hardest thing was having so many patients in the ICU as one person takes at least two or three nurses with the dressings, which can take three or four hours each. It’s stressful for the nurses, stressful for the surgeons who have to operate on them, and stressful, of course, for the patients.'

Image: Supplied.

Under Her Skin is now available for purchase, here.

Feature Image: Michael O'Brien/WA News.