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By Lieutenant Commander Bryan J. Hawkins, Medical Corps, U.S. Naval
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Within a two-year period, the small medical staff at the isolated naval hospital at Subic Kay carried on through an earthquake, the Gulf War buildup, and the eruption of Mount Pinatubo (left). It may not have been combat duty, but some days it felt like it.
The operation of a major medical facility in an isolated area poses many interesting challenges to the military physician. The U.S. Naval Base Subic Bay is by no means small—being the largest naval facility outside of the continental United States—but from a medical standpoint, the Republic of the Philippines is extremely isolated. Compared to stateside hospitals, U.S. Naval Hospital (USNH) Subic Bay is staffed by a skeleton crew of °nly absolutely essential medical corps, nurse corps, medical service corps, and hospital corps personnel. It is here that the unique isolation of USNH Subic becomes aPparent.
Naval Hospital Subic is completely removed from all Medical facilities not available in-house. Acceptable Fil- jpino medical assets are limited, making the naval facility highly dependent on an intact medevac system. Mede- vac evolutions within or out of the Philippines can involve hours or even days to complete. Unfortunately, the practice of medicine does not afford us hours to intervene in Certain medical situations. This frequently mandates compromise on the part of the practitioners—an uncomfort- ahle position for any health-care provider.
With a primary mission of support for the fleet, USNH Subic Bay truly stands out. The challenges faced routinely, c°nsidering the constraints on the facility, are unique in hJavy medicine. During the course of a two year tour of huty in the Philippines, I experienced two natural disasters of epic proportions. Other more “routine” disasters frequently impacted normal operations. Political unrest, qualifying for hazardous duty pay, was the norm. During 'he buildup for Operations Desert Shield and Desert Storm, the naval station saw its heaviest port loading since ’he Vietnam War, placing tremendous strain on the personnel and supplies of the Medical Treatment Facility (MTF). Coup attempts and base negotiations mandated r°utine lockdowns of the facility, adding morale problems ’° the mixture.
Regular operations at the MTF continued, undaunted hy all that occurred around it. The following is a sum- 1,1 ary of the direct impact of three major events, over the c°Urse of two years, on the MTF: the July 1990 earthquake on the island of Luzon, the June 1991 eruption of ^ount Pinatubo, and the buildup for Desert Storm.
7/jc Earthquake of July 1991, Luzon, The Philippines
On 17 July 1990, the Republic of the Philippines ex- tenced an earthquake of tremendous magnitude. Reg' 7.7 on the Richter Scale, this quake was the
The epicenter was approximately 60 miles north of Manila, near the town of Cabanatuan, but its effects were widespread.
The San Francisco quake of October 1989, which registered 7.0 on the Richter Scale, devastated many structures, but loss of life was miraculously low. This was not the case in the Philippines. Structural damage was localized in the more urban areas, primarily Cabanatuan and the city of Baguio. Numerous buildings collapsed, trapping thousands of people. The death toll ultimately would approach 2,000. The primary reason for the high fatality rate was the inability of the local communities to communicate their need for assistance, as the quake had knocked out normally used lines. There was also a shortage of equipment to extricate the hundreds of people trapped in the rubble of collapsed buildings.
The response of the U.S. Naval Facility, Subic Bay, was rapid and extensive. Air assets, machinery, and personnel were deployed to assist in the search, rescue, and in some cases the ultimate medical care of the earthquake victims. A contingency readiness team (CRT) of physicians, nurses, and hospital corps personnel was deployed from the U.S. Naval Hospital to Cabanatuan to assist in any way possible. Any medical supplies that could be spared were sent as well. Preventive medicine specialists were employed to assess water supplies and sanitation. Backup teams were held on ready status for deployment as needed. Hospital operations proceeded cautiously, anticipating casualties. Similar operations were being conducted in the city of Baguio by the personnel from Clark Air Force Base.
At the scenes of greatest destruction, rescue efforts were crippled by the lack of heavy equipment to move rubble. The efforts were largely individual: Americans and Filipinos would crawl, at great personal risk, into the collapsed buildings. Rescue was slow and poorly organized. Hundreds of people remained trapped in rubble, with crushed limbs or torsos, for upwards of 30 hours in the intense summer heat.
By comparison, the rescue efforts after the San Francisco quake were quick, organized, and well equipped. Very few victims were subjected to prolonged crushing. Medical personnel as a rule do not see this clinical entity in the United States.
The medical implications of prolonged crushing are profound and frequently life threatening. The crush syndrome involves the release of toxins from the death of muscle cells, and victims are subject to shock, kidney failure, and cardiac dysfunction. The clinical course of the crush syndrome usually is protracted and progresses despite concentrated, modem resuscitative efforts. The victims treated at the naval hospital had complicated clinical courses, involving many surgical procedures and massive efforts on the part of all care providers. All of the patients eventually succumbed to their condition. In fact, the vast majority of the fatalities occurred well after the earthquake. In Baguio, a collapsed hotel caused the deathjof nearly 1(¥) people. Onlytseven of the \|ctims died as § result of ditect injuries frcjm the collaps*; tffe rest suc&mJid to the stelae of thp^t^h syndrcfme. j y
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Operations Desert Shield and Desert Storm: The Buildup
The military buildup for Operations Desert Shield and Desert Storm had a profound effect on the naval hospital. Many of the military personnel staged from the West Coast by ship passed through the Philippines. Port loading was at its highest level since the Vietnam War. By stateside standards, the Subic MTF had a skeleton crew, and sometimes had difficulty providing for even the local eligible population. There were no medical or surgical subspecialties and each department was staffed with a minimum number of providers. The facility was tasked with providing medical support to all shipboard commands as they passed through. On average, the port usually handled requests from eight to ten ships per month. During November and December 1990, just prior to the start of the war, the port handled 32 and 38 ships, respectively. As would be expected, there was a proportional increase in the number of requests for medical services.
Most of the requests fell into the realm of medical readiness rather than acute medical care. This impacted two departments that were particularly poorly suited for large fcreases in patient loads. These departments—audiology optometry—were staffed with Medical Servicje'florps
providers only and did not have the luxury of a Medical Corps provider.
In November 1990, more than 700 requests for audiology screening were accommodated. The normal monthly request load averaged less than 100. The optometry de-1 partment, already one of the most overburdened at the fa-, cility, also saw a staggering increase in requests for services. One optometry technician spent one 72-houfj weekend fabricating more than 250 pairs of corrective lenses, to assure 100% readiness.
The MTF at Subic Bay relied heavily on an intact mede- vac system. Because Subic lacked 3 full complement of subspecialty sur-1 gical and medical providers and had minimal intensive-care capabilities, many patients required medevac fof those services. The U.S. Air Force Hospital, Clark AFB, frequently wa* used—depending upon its availabil- ity—as the scope of the Clark facility was much greater than Subic’s.
There always was a great need fof medevac services, which were diminished for an extended period of time during Operation Desert Shield Practically all of the Military Airlif1 Command assets normally present i® the Western Pacific theater were dedicated to the transport of troops and equipment to the Middle East. Mede- vac flights, usually plentiful, became a rarity. This compounded both the clinical and administrative burden* j of patient handling for the facility' Additionally, during a six-month pe' riod starting in September 1990' more than 270 patients were medically evacuated from their deploy' ment back to the Philippines. The majority of these patients required either psychiatric or orthopaedic services, and many needed administrative dispositions and return to the States. The facility at Subic Bay wa* not capable of long-term support f°f personnel not already stationed there , The primary mission for any military medical facility- whether overseas or in the United States, is support of the fleet. Implicit within this mission is the fact that, whe” the situation warrants, all other operations must giye way to fleet support. This concept was never violated h1 the Philippines, but some lessons might be learned for th6 future. I
Medical personnel from operational commands or ever providers at the stateside facilities depended on the Sub>1 medical facility to complete predeployment tasks not acJ. complished. Personnel simply should not be deployed j they are not ready, including i ledically prep*ed.jA sol' rer \yould not be deployed wit lout/a functioning jwpap0"
Hospital personnel gave much of themselves to the host population. Medical and dental civic action programs were conducted regularly—on nonwork days—to bring health care to the Filipinos.
is not fully ready from a medical standpoint.
Additionally, stateside facilities are far better equipped to accomplish screening and other services. For such facilities to depend on an isolated MTF to finish the job is neither prudent nor appropriate. The Subic Naval Hospital mustered the necessary can-do spirit and completed the mission. In the future, however, this may not be feasible—especially if the next conflict does not provide the luxury of a six-month preparation period.
Mount Pinatubo: The Eruption
In April 1991, after 600 years of inactivity, signs of life appeared in a small volcanic mountain about 20 miles northeast of the Subic Bay naval facility. Teams from the Philippines Institute of Volcanology and Seismology, as well as a volcano crisis team from the U.S. Geological Survey, immediately set up monitoring stations around the mountain. During the first 24 hours of monitoring, more than 490 volcanic quakes were detected—indicating new life in the slumbering giant.
Activity increased dramatically in late May. Monitors indicated that the slopes of the mountainside were actually bulging under the force of the buildup below the surface. Small eruptions began during this time, sending plumes of volcanic ash as high as 65,000 feet into the sky. As concerns mounted, it was decided to evacuate all nonessential personnel from Clark AFB, located only eight miles from the peak. In the early morning hours of 10 June, the evacuation of Clark was ordered, and a convoy of more than 15,000 people started toward Subic Bay. The evacuation, it turned out, was well timed, as two days later the major eruptions commenced. What could not be predicted, however, was the effect the eruptions would have on Subic, the ostensibly safe place to be.
On Saturday, 15 June, the major eruption took place, complicated by heavy winds and rain from typhoon Yunya. The odds that these two natural disasters would occur simultaneously was “a ten-million-to-one shot” according to one volcanologist.' The prevailing winds sent tons of ash raining on Subic Bay, paralyzing the base. The ash cloud obliterated the sunlight. At noon that day, it was as dark as midnight. The daylight did not return until the next morning.
The overall effect of the volcano/typhoon on the U.S. military facilities now is well known. On the Subic naval facility alone, more than 250 buildings were destroyed. Miraculously, only two people were killed, when the building they occupied collapsed. Numerous other lives were saved by the local engineering personnel, who, during the night, ordered the evacuation of other structures deemed In one instance, a building collapsed literally within of its evacuation. Power was lost, as was the abil- water. Transportation was cripp roads were rendered impassable. Communications wer£ severely affected as well. On the Monday following the major eruption, the base was deemed unfit for living' and the order was sent out for the evacuation of all de' pendents—and subsequently of all nonessential military personnel.
The effect on the delivery of medical care at the U> Naval Hospital Subic Bay was profound. Prior to the major eruption, the eligible population increased as a result 0 the evacuation of Clark. This ultimately would be seen a* a minor disruption in the daily operation of the facility^
On the day of the eruption, the major concfrn was
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It has been stated in discussions of military medical ’eadiness that, “In many continental United States locals, medical personnel had lost their close association With military operations.”2 This statement was made in the tQntext of medical readiness for wartime, but it may have ’elevance in peacetime as well. The practice of medicine 111 ’hat isolated setting was an invaluable experience. Lack- Jtig the comforts of backup and consultants, and faced with aging facility, one learns to be resourceful and toler- aPt very quickly. One gains appreciation for the norm of P^dical care delivery in the States, both civilian and Military.
f In addition to the major events discussed here, other ”ctorf influenced the day-to-day life in the Philippines. TPar|nt% politically motivated killings caused the Philip- Plnes to be designated hazardous duty, meriting hostile
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nurses, and corpsmen, male and female—were set up. In the darkness, personnel spent hours shoveling the wet ash, now more like wet sand, from the roof, to try and keep it from collapsing. The work was backbreaking, conducted *0 the midsummer heat and humidity, but the effort ultimately was successful.
After the eruption, the practice of medicine became Primitive. Although the hospital building was saved, there "'as no power, no water, and no ability to store food. Emergency power was generated at the facility but was ^equate to provide lighting for the operating room, the emergency room, and one patient ward. On the day of the eruption, a number of patients were injured and required emergency treatment and even surgery. Equipment and instruments were found by flashlight. The building continued to shake from the nearly 100 tremors that confined throughout the day.
The facility was without water for about four days, and afrer that what was available was moved in by water buf- frtlo. Water was rationed. Personnel could not bathe initially. Concessions eventually were made so clothes could washed. Approximately two weeks passed before the normal water supply was restored to the hospital.
Pood storage and preparation was virtually impossible. In the first few days after the eruption, food was pro- tided to patients in the form of MREs (prepackaged ’Peals for field consumption). Patients were allotted one IriRE per day. The hospital staff ate whatever nonperishable food stores were left in the galley. This usually meant Stines and peanut butter by candlelight. The facility was Perpetually dirty with ash, with no capability for adequate cleanup. Ash-clogged gutters caused numerous leaks ‘nto the hospital building. Standing water in the hallways was common.
The saving grace was the evacuation of the base. This Pfrmmized the patient load and reduced the operational requirements of the hospital. Once the situation stabilized, efforts were directed toward cleanup. It was fortunate that mass casualty situation arose during this time, as the ability of the facility to respond would have been greatly c°mpromised. Operations returned to normal very slowly.
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fire pay. Frequent base lockdowns associated with base negotiations and other politically controversial events tested the nerve and patience of all stationed there. Natural disasters are commonplace; this country of more than 7,000 islands is hit with more than 20 typhoons in an average year. The Subic facility was crippled by one typhoon with sustained winds of 95 miles per hour. Electricity was out for three days. Exactly one week later, a “super typhoon,” with sustained winds of 150 miles per hour, headed straight for Subic, then veered northward as it made landfall, hitting northern Luzon. The potential disaster can only be imagined. Relief efforts were organized, regardless of the areas involved, to assist the local populations.
The hospital personnel gave much of themselves to the host population on a daily basis. Medical and Dental Civic Action Programs (MEDCAPS and DENTCAPS) were conducted regularly, sometimes two per month and always on a nonwork day. Civilian humanitarian cases were referred to the hospital regularly as well. One particular surgical provider performed more than 400 facial reconstructive procedures on locally referred patients. Efforts were made to contact local physicians and provide help in any way possible, if only as consultants. Calls from local health-care providers frequently requested that the facility take on ineligible patients with a variety of problems, most commonly trauma victims. Requests such as these were handled on an individual basis.
As individuals, the Filipinos were universally grateful. On a larger scale, however, the Americans did not feel altogether welcome. After U.S. personnel assisted in the rescue of 137 people in the aftermath of the earthquake, critics voiced the opinion that “. . . this reliance [on the Americans] inhibits national development by fostering a ‘colonial mentality,’ where Filipinos look up to the Americans and down to themselves. ”
This underlying attitude, coupled with the hardships already present from a medical standpoint, made it very difficult for even the most optimistic person to maintain a positive outlook.
Duty in a setting such as this cannot compare to the physical and emotional hardships of combat duty, but in peacetime it presents unique challenges not found elsewhere. It could certainly be argued, if one looked out over the Subic Bay the day after the eruption of Mount Pinatubo, that some sort of battle had in fact occurred there.
'K. P. Mukri, “Out From the Ash," U.S. Naval Institute Proceedings/Naval Review, July 1992.
2BGen G. K. Anderson, USAF, MC, “A Decade of Great Progress in Medical Readiness,” Military Medicine, 155, 11:535, 1990.
3“U.S. Help in Earthquake Divides Filipinos," The Pacific Stars and Stripes, Associated Press, 20 July 1990.
Lieutenant Commander Hawkins is an orthopaedic surgeon on the staff at Naval Hospital, Bremerton, Washington. His Navy career has included a tour as a staff orthopaedic surgeon at Naval Hospital, Charleston, South Carolina, and at Naval Hospital Subic Ba>c where he served^s Head, Dcparunent of Orthopaechc Surgery, and a
apd'completed a liatei