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Clean and Clear on Khao Lak Beach

A flag hangs limply on its bamboo pole. "Clean and Clear" are printed on it. A search and rescue team planted the flag on this Asian beach six months earlier, and the area looks not much different than it did then.

The "clean and clear" designation is in name only- occasional bodies are still being found. Col. Khemmarin Hassiri of the Thai Tsunami Victim Identification Center in Takua Pa believes there are hundreds still missing. 1

The beachside is bulldozed and wide open. The remains of resorts are in view. Thousands of foreign tourists were vacationing here when the tsunami came and swept them and everything else away.

Memorials to victims can be seen around the area. One picture tacked to a palm tree remembers a child named Saga Kalm. The picture on another tree is of a Sophia Stuermer. Loved ones of tsunami victims set up the beachside memorials. They represent a call to action for the international community to work to improve emergency medical services here and throughout Asia.

Organizations such as the Association of Southeast Asian Nations (ASEAN), the World Health Organization (WHO) and the United Nations Educational, Scientific and Cultural Organization (UNESCO) are leading the way for improvement. 2-4 One of the goals is to "reduce avoidable mortality [during disasters]." 3 To do this, the locals here need a better EMS and disaster-response system.

The need is urgent, especially with another tsunami feared imminent. 4,5 This call for action means applying lessons learned from the 2004 disaster. In this article, we will review the tsunami's destruction, the EMS response and how to act on the lessons learned.

When the 9.0-magnitude earthquake occurred last December in the Indian Ocean, it generated a huge tsunami that struck surrounding countries, killing more than 200,000 people and injuring hundreds of thousands more.

Wave heights varied. In parts of northern Sumatra, they approached 80-90 feet. 6,7 In Khao Lak (Takua Pa, Phangnga,Thailand), they were up to 35. 8 The enormity of those waves is evident when you see a Royal Thai Navy vessel carried more than a mile inland. Resorts and small structures near the beach were simply washed out to sea. Other resorts crumpled. Another 80 miles south in Phuket, the waves weren't as high, yet 279 people were killed and close to 3,000 injured.

Vacationing American health professional Mark Oberle, MD, was in Phuket when the tsunami struck. "In the first two hours," he says, "if you couldn't get up to the second floor, you would not survive, because of the still-incoming waves." 9

The injured thousands who managed to escape the initial onslaught faced new problems. First responders could not reach the scene. Fallen trees, debris, ships, vehicles and bodies blocked the road. Oberle taught a crash course on bleeding control to a group of volunteers in his hotel lobby. 9

In Khao Lak, one stretch of Highway 4 was covered in five feet of mud and debris. Many walking wounded were able to make their way to the hospital, but trauma victims were not. Telecommunications were severely damaged, crippling needs-assessment efforts and leaving local EMS on their own.

I belong to the Emergency Medical Reserve (EMR) team of Raksakon Hospital in Sakornakon. When our team leader, Dr. Kittisarapong, tried to find out if our team was needed, he could not make contact because of the damaged telecommunications network. With communications down, EMS turned to the media to receive information necessary to make response decisions.

According to Dr. Tunakorn Pongwant of Vachira Hospital, "Even though [Patong Beach, Phuket] is only 20 minutes away, it took three hours before victims started to arrive at the hospital." Czech fashion model Petra Nemcova received a pelvic fracture and clung to a tree for nearly eight hours before being rescued. 10 Others died who would have lived if rescuers had arrived sooner. 11 As IBM's Worldwide Crisis Response Team Manager, Brent Woolworth, summed it up, "If you can't call for help, you can't get help." 12

Hours after the tsunami, the world started to realize the scope of the catastrophe. The nation of Thailand sprang into action, with Prime Minister Thaksin Shinawatra leading the way. A team of about 200 personnel from Siriroj and Ramathibodi hospitals made its way to the airport, where it was transported to Phuket in an air force C-130. 13 The entire Thai government, its military and 20,000 rescue workers mobilized a massive emergency response. Included in this was a Royal Thai Army Search & Rescue (SAR) dog team responding on its first mission. 14

In Indonesia, a group of nongovernmental organizations (NGOs) started to recruit volunteers to form a SAR team to respond to Aceh Besar.

Back in Takua Pa, the injured made their way to the hospital in all sorts of vehicles. Surgeons Kannikar Laohavichit and Kajohusak Kawjarus operated for 24 hours straight before additional surgeons arrived.

Thirty-two hours after the tsunami, Thailand requested international support, which included search and rescue.15 Teams came from around the world, including Singapore, South Korea, Hong Kong, Taiwan, Japan, France, Germany, Greece, Great Britain, the Order of Malta, Israel, New Zealand, Mexico and the U.S. 16-21

In Taiwan, volunteers from the International Headquarters SAR Taiwan (IHSART) team were given the green light to respond only if they could get time off work, raise their own funds and be completely self-sustained. They worked hard raising support and finally, 48 hours after the tsunami hit, were able to respond. Surprisingly, Taiwan's was the first international SAR team to arrive in the Thai disaster zone. 21 The Navy moved in as well, and had its only aircraft carrier stationed off the coast of Phuket. At that point, the Thai government decided to transfer all injured foreigners to Bangkok or fly them home. 13

Most SAR teams arrived in Thailand four days after the tsunami, and the United Nations Disaster Assessment and Coordination (UNDAC) group assigned each team a three-mile stretch of devastated coastline. 22 Teams from the U.S. and Mexico and another from Taiwan arrived in Indonesia, and the Israeli team arrived in India.

In Khao Lak there was no power, so SAR teams had to stop working at 6:30 p.m. each day, slowing their progress.23 German SAR member Ulf Langemeier summed up the search and rescue operation: "There's always a chance of finding someone trapped under rubble when an earthquake strikes on land, but when waves enter a building, you have no chance." 23

With my Mobile Medical Unit team in Takua Pa, we treated a couple hundred victims. Mostly we cleaned infected wounds and provided counseling for victims with psychological trauma.

I met up with a Thai first responder. His ambulance didn't have much more than a stretcher in it. I showed him one of my American EMT books, and his eyes lit up as he looked over the equipment American EMTs use. "Wow!" he said. "I wish we could be equipped like that."

Such is the situation for first responders in Thailand. Theirs is a system that mostly provides first aid and "load-and-go" transports of patients to hospitals. These workers generally have little education and training and are paid minimally.

The Thai EMS system had been declared inefficient even before the tsunami struck. The Institute of Transportation Studies/U.C. Berkeley Traffic Safety Center's 2004 paper, Prehospital Care of Road Traffic Injuries in Chiang Mai, Thailand, points out that "Thailand's national and local prehospital services (i.e., services designed to transfer persons with traffic injuries into the country's hospital infrastructure) are both insufficient and inefficient. Research recommendations for Thailand EMS include more professional training for emergency workers, standardization of equipment, centralization of communications, and further analysis of competitive services." 24

To improve EMS response in the areas affected by this event, the international community needs to make a commitment to act on the findings of the World Health Organization's May 2005 Conference on Health Aspects of the Tsunami Disaster in Asia. At this conference, aspects of the response and recovery efforts following the earthquake and tsunami were studied. Participants concluded that there was a need for a stronger disaster management system to lessen suffering and the incidence of death when disaster strikes.

Participants from national governments confirmed that they are ready to become better prepared by implementing the following elements identified by WHO's head of crisis operations, Dr. David Nabarro:

1. A stronger capacity for vulnerability reduction through (a) updated policies and legislation, (b) restructuring of disaster management authorities and (c) funding that can be used for vulnerability reduction and disaster preparedness.

2. A stronger post-disaster needsassessment capability, with a focus on prompt assessments and using WHO-standardized health assessment tools.

3. Better networking to learn from each other's best practices in vulnerability reduction and disaster response. We profit from evidencebased guidance.

4. Better coordination between disaster response groups, achieved through preplanning.

5. Enhanced supply systems, communications and logistics. Supply management and logistics should be self-sufficient so as to not impose additional burdens on affected communities.

6. Better integration of voluntary bodies in preparedness and response. These should be central, not marginal, to preparedness and response efforts. Their response should be timely and result in the needs-based deployment of available resources.

7. Donors and donorship requirements that are timely, sustained, appropriate and with flexible funding.

8. Further cooperation of government military forces and the commercial private-sector response, alongside local and national government, civil society and NGO cooperation.

9. Improved local, national and international media relationships, as media are key partners in helping shape the policy agenda for disaster preparedness and response. They are also important during disasters as information sources on health issues and for identifying myths that hinder response efforts.

10. Commitments to being fully transparent in terms of the standards of performance to which we aspire. We all should be honest in our own performance evaluations.

Local communities must be enabled to develop cross-sector capacities for vulnerability reduction and effective disaster responses, and receive financial and technical backing to do so. 26

Thailand's goal is to accomplish the above recommendations, and I challenge EMS Magazine readers to be a part of helping the country succeed. At this time, I'm working with the EMS director for this province in striving to develop a first-class EMS system. If we are successful, we can be a role model for the rest of Thailand. Donation of equipment is needed, as well as used EMT books to give to hospital directors so that they can understand American standards. Partners are also needed to provide professional training. Wellfunctioning professional EMS networks can coach Asian communities and national governments to develop a first-class EMS response system.


  1. Reuters. Thailand resumes grisly search for tsunami dead. May 20, 2005.
  2. Relief Web. Statement by His Excellency Dr. Kantathi Suphamongkhon, Minister of Foreign Affairs of Thailand. May 12, 2005.
  3. World Health Organization. 58th World Health Assembly, provisional agenda item 13.3, May 16, 2005.
  4. Relief Web. Thailand: Field Situation Report No. 15. June 13, 2005.
  5. Macey R. Quake may be "imminent" warns tsunami expert. Sydney Morning Herald, June 9, 2005.
  6. Paulson T. Tsunami experts meet at UW to study disaster. Seattle Post-Intelligencer, June 13, 2005.
  7. Gibbons H, Gelfenbaum G. U.S. Geological Survey. Astonishing wave heights among the findings of an international tsunami survey team on Sumatra. March 2005.
  8. INET. Tsunami Relief Information: Worst- Struck Areas. June 11, 2005.
  9. Oberle M. Northwest Center for Public Health Practice. Tsunami 2005: Understanding tsunamis; lessons learned from Phuket; and the nature of international response. February 14, 2005.
  10. Web India 123. Petra Nemcova revisits site of tsunami terror. June 12, 2005.
  11. Dolcetti J. Rescuer's story... Joseph Dolcetti. Jan. 7, 2005.
  12. Woolworth B, panelist. WHO Conference on Health Aspects of the Tsunami Disaster in Asia, May 4-6, 2005.
  13. Ministry of Public Health of Thailand. Health aspects and the management of the tsunami disaster. WHO Conference on Health Aspects of the Tsunami Disaster in Asia, May 4-6, 2005.
  14. U.K. Fire Service, Urban SAR Dog Teams. Post Incident Report-Indian Ocean Tsunami.
  15. Relief Web. Thailand: Field Situation Report No. 2. Dec. 28, 2004.
  16. Royal Thai Embassy, Tokyo. Assistance from Foreign Governments and International Organizations. January 23, 2005.
  17. FEMA. Emergency Managers National Situation Update, Jan. 2, 2005.
  18. Ng D. Disaster rescue plan revealed. The Standard, June 2, 2005.
  19. United Nations Office for the Coordination of Humanitarian Affairs. INSARAG-SAR Directory.
  20. Relief Web. Regional Contributions- Earthquake/Tsunami, December 2004.
  21. Heroes in red: Taiwan's international search and rescue volunteers.
  22. Singapore Civil Defence Force, Ministry of Home Affairs. Factsheet update on Singapore's Emergency Response Ef for ts. Janua r y 1, 2005.
  23. China Daily. New tsunamis possible; residents flee. December 30, 2004.
  24. Singapore Civil Defence Force, Ministry of Home Affairs. Reinforcement Lionheart contingent to beef up search operations in Phuket. January 1, 2005.

  1. Institute of Transportation Studies, U.C. Berkeley Traffic Safety Center. Pre-hospital care of road traffic injuries in Chiang Mai, Thailand. 2004.
  2. Nabarro D, presenter. WHO Conference on Health Aspects of the Tsunami Disaster in Asia, May 4-6, 2005.

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