Whakaari / White Island Erupted

On 9 December 2019 New Zealand’s Whakaari White Island erupted, ultimately killing 21 of the 47 people who were on the island at the time.

 

This extraordinary event attracted global attention and resulted in hours of life-saving surgeries within burn units across the country, with support from the National Burn Centre team at Middlemore Hospital.

The response was unrelenting. Some patients were severely injured with burns to up to 90 per cent of their bodies. The average burn size was 50 per cent. Surgeries were required overnight for the first three days and daily until the New Year. The workload took its toll on staff, yet as they reflect on those intense months, along with the struggle, they remember remarkable ingenuity, solid planning, networking and enduring goodwill from staff and public alike.

In the moments after the eruption, information was scant, but even then the seasoned trauma specialists who led the medical response recognised this was unlike anything they’d seen before.

“Nothing in our wildest imagination in all the exercises we ran did we come up with a volcano erupting with people on it,” says Tracey Perrett, National Burn Service Coordinator.

Members of the team recall the first communication they received alerting them to the disaster.

Clinical Director, Surgery, Anaesthesia and Perioperative John Kenealy, had just wound up a meeting at 4.30pm at Middlemore Hospital’s Ko Awatea rooms when he received a text saying only that there had been an eruption on White Island.

The group, including CM Health Chief Executive Officer Margie Apa headed straight to Middlemore’s Incident Management Room and didn’t leave it until hours later. Mr Kenealy describes feeling adrenalin and uncertainty.

“You just sort of think ‘OK, there’s been an eruption. Is it one person [injured]? Two people, no people or 100 people?” he says.

Plastic Surgery Consultant and Head of Department Michelle Locke was at her private practice that Monday afternoon. As always, her phone was on silent but rang so incessantly she told her patient she would need to answer. All she learned was that the volcano had erupted.

Meanwhile, clinical leader of the Burn Service and plastic surgeon Richard Wong She was at Middlemore working in an environment that was already stretched. He describes a ‘strange and ominous’ limbo as they waited for more information.

“Phase one was ‘impending doom’. We had no idea how bad it was going to be and that was really hard,” Mr Wong She says.

“We didn’t even know how many people were on the island,” adds Ms Locke. “There was a delay of hours because it took that long for boats to come back from the island and it wasn’t until they were offloaded at Whakatane [Hospital] and staff were able to look at them that we could get any clear information.”

By 10 o’clock that night the first two patients had arrived. A burn surgeon was still in theatre operating on the list of existing ICU patients. He continued until 2am, then he joined the Whakaari team in the other theatre until morning.

Mr Wong She stayed until 1am as the enormity of the situation began to hit. He’d earlier summonsed the on-call Plastic Surgeon and the on-call Hand Surgeon (who is also a plastic surgeon) to take the first White Island patient into theatre while he triaged incoming patients.

“We had a year’s worth of work referred in one day. We ended up running four operating theatres during the day and one overnight for those first three days. In the first week we spent about 5900 minutes operating on White Island patients, and on top of that we had 2200 minutes on our existing burn patients. We normally have 1400 minutes a week allocated to burn patients. It was huge but I can tell you right now that we in no way compromised the care of any of those patients,” he says.

And it wasn’t just the National Burn Centre at Middlemore that was under pressure. All of the regional burns units (Waikato, Upper Hutt and Christchurch) stepped up and took on patients over and above their normal workload. The combined efforts of all of these units were needed to provide the much needed care for patients.

“[Whakaari patients] got the same care as they would have if they’d been the only patient on the burn unit,” Ms Perrett adds. Despite the severity of the disaster, the National Burn Unit was well placed to manage the National response, Ms Perrett says. “We move patients up and down the country all the time – we don’t usually do it for as many patients but we just ramped up what we normally do.”

Having a system in place that could be scaled up was key to being able to respond efficiently, agrees Ms Locke. “It is important to have a system in place that can scale up. You don’t want to have to put a new system in place for a disaster – you want to have these systems in place beforehand and scale them up as you need them because people cope with that much better than coping with something totally new,” she says.

Another strength of the national response came down to a mandatory training requirement for all New Zealand plastic surgery trainees to rotate on the National Burn Team. The National Burn Centre had also spent time upskilling staff from other hospitals in the treatment of burns with organised education days and rotations through the National Burn Centre.

Initial operations on patients focussed on removing dead tissue or debriding wounds which then required temporary, biological dressings in the form of cadaver skin. For some of the patients with larger burn injuries, this was replaced with a new skin substitute as a means of controlling the wounds without needing to continually replace the temporary cadaver skin.

Later, skin was harvested from the patient and grafted where required, and for people with extensive burns, this process had to be repeated in multiple steps to achieve total coverage due to the limited amount of donor site. The survivor with the most extensive burns needed 80 per cent of his body to be replaced by the remaining 20 per cent of unburnt skin.

Surgeries were long and hot. To help maintain the body temperature of a major burn patient operating theatres had to be heated up to 32 degrees.

It was essential that rosters were realistic and the welfare of staff was taken into account, Ms Perrett says.

“We had anticipated that you can’t work 24 hours a day forever. We’d often talked about other examples of disasters where people did heroic things such as operating for days without breaks. That wasn’t the model we wanted to use. Michelle quickly put together a roster of surgeons for the days and weeks ahead to allow us to operate safely.

This involved a huge amount of goodwill from burn surgeons who cancelled scheduled leave, to plastic surgeons who willingly stepped into supportive roles. Surgeons, nurses and occupational therapists arrived from Australia and the UK.

On top of the support from the regional burns units there was also local support.

“I had the head of radiology going around inserting feeding tubes down patients in ICU and saying ‘Right, who’s next?” I was afraid to say anything in case he put a tube down me,” jokes Mr Wong She.

Goodwill was widespread and enduring. Orderlies stayed late during those critical first days and other services graciously accommodated disruption to their regular schedules.

The public support was also remarkable– from the misguided offers to donate skin to more practical deliveries of food – everyone wanted to help.

“The community baking was awesome. Sometimes you come out of surgery and you just need comfort food,” Ms Locke says.

Networks of old medical school mates and other contacts also proved invaluable. A key piece of equipment in the treatment of burns is a mesher which is used to make strategic incisions in the skin graft to enable it to be stretched to cover a larger area. High theatre volume meant more of these were required than usual so the team asked contacts from across the country for help. One was personally driven halfway from Waikato hospital by the theatre co-ordinator working there that weekend. Ms Perrett drove to Pokeno to collect it from someone she’d never met.

“I had to text him: “I’m outside Pokeno in a green shirt. It was like a bad blind date,” she laughs.

Similarly, when it came to identify the correct people to help fast track Medical Council registration for surgeons from overseas, it helped to know the former Council Chair, Andrew Connelly, who is also a clinician at CM Health, says Ms Locke.

“[I rang him to say] ‘Hey, I’ve got a problem, Andrew can you help? And within five minutes I was on the phone to the right person and we had emergency registration through that afternoon. He just helped navigate things that otherwise seemed impossible,” she says.

“Medicine is a really small society in New Zealand. There are a lot of doctors but there is definitely the one degree of separation phenomenon. Somebody you know will be able to access this or get that.”

After many years at the Burn Unit, the close knit team is used to treating trauma, but the intensity of those months and the human toll still have significant impact, Mr Wong She says.

“How do I describe the moment when there is a wife (and mother) having an anaphylactic shock who then dies in ICU while her husband (and a father) is in theatre about to lose his airway?”

The man almost died within minutes of his wife but the team were able to save him that night. Unfortunately, despite “Herculean efforts” from multiple teams, the husband eventually joined his wife 40 days later.

That couple left behind three children.

The event also impacted the families of staff.

“One of the hardest parts for me personally was that despite telling my family that they were the most important people in my life, every action over those first few months screamed otherwise. And it wasn’t just me – it included my colleagues who delayed holidays or those who volunteered to work public holidays. Over Christmas and New Year when families spend quality time with each other, everyone involved was spending quality time with their ‘other’ family” Mr Wong She says.

Nearly six months on, the arrival of COVID-19 before the last of the White Island patients were discharged has prohibited the extensive debriefing which would be the normal course of events.

There will, no doubt be valuable lessons to be learned but the feeling overall is of a job collectively well done.

Says Clinical Director of Surgical Services John Kenealy: “The speed with which the patients were treated and the relative lack of serious complications was as good as we would expect under any circumstances when we’ve actually just had one or two patients.”

In the end, of the 13 patients at Middlemore, two were repatriated to Australia and three died of their injuries. The rest were able to return home, including a young guide who had suffered burns to 80 per cent of his body.

Mr Wong She says the event showed the strength of the medical and wider community.

“We’ve all been told that we need to be kind to each other. My feeling is that while we have been at Middlemore we have felt that. That is what we experienced during White Island. If we carry that through we’re in really good heart I think. It means that all the things that we’ve been through will make us stronger for whatever challenge we might face next.”