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Skip and I visited Rick this morning. Rick did not have a good night. Skip has been there all day and will no doubt give a full update later when he returns.
This is a big posting (sorry about the size) but there is no weblink to this. This is the transcript of the article on the Doctors and Nurses who are caring for Rick. Rick is mentioned fairly extensively towards the end of the article.
The healers
Author: Liz Porter
Date: 20/10/2002
Words: 2900
Publication: The Sunday Age
Section: Agenda
Page: 1
Last week Thomas Kossmann spent hours in theatre operating on burnt skin and comforting the distraught relatives of the six Bali bomb victims in his care. As head of the Alfred Hospital’s trauma unit, Kossmann has just endured the week from hell. Liz Porter spent the day with him.
It’s 7.25am as Professor Thomas Kossmann turns his silver four-wheel drive off Commercial Road and into the car park adjoining the Alfred Hospital’s helipad. Within moments he is striding through the emergency department entrance. It’s Thursday and the six victims of last Sunday’s blast have just begun day five of their ordeal, lying bandaged in the hospital’s intensive care and burns units. The next few days will be crucial for them. Between day three and day seven patients who have previously seemed to be doing well can go into a dramatic decline when septic complications set in and stressed vital organs begin to fail. “People feel well in the first one to two days,” the surgeon says. “They have been resuscitated, they feel fine, and then after three to four days, they deteriorate and they can die due to septic complications.”
Kossmann, 43, has been in a state of high alert since the moment he heard the news last Sunday. At midnight on Monday he was on the phone organising a list of surgeons for the following day.
At 6.30am on Tuesday an ambulance carrying Canadian national Richard Gleason, 38, the hospital’s first Bali burns patient, arrived after being flown in on a Lear jet fitted out as a mobile ICU. Gleason, a business analyst, had made a last-minute decision to holiday in Bali instead of Mexico and was walking around the island with his backpack on after the blast. The adrenaline and shock kept him going, but now he is critically ill with burns to half his body.

Later that morning another four patients flew in via RAAF Hercules from Darwin. By Tuesday afternoon, along with burns unit director Heather Cleland, Kossmann was moving between four operating theatres, supervising the “debriding” (the excision of dead and infected tissue) of burns and shrapnel wounds. Six surgical teams had been ready and waiting for the arrivals and 50 minutes after being taken into the hospital, the victims were in theatre.
“That was a tremendous time because we had to re-evaluate them, resuscitate them and X-ray them,” says the surgeon. “They did a tremendous job in Darwin. We knew exactly what we were getting.”
All Wednesday, Kossmann was in and out of the hospital’s operating theatres, working on one severely injured burns victim for a four-hour session of tissue-debriding and reconstruction work. Finishing surgery at 7.30pm, he then sat down for a long discussion with the relatives of another patient.
The German-born surgeon, who was head-hunted from Zurich, joined the Alfred last September. Although he describes himself as psychologically “robust”, the Bali victims are a vivid reminder of an experience that has proved to be the best possible preparation for the demands of the past week – and the difficult weeks ahead.
On August 28, 1988, three Italian fighter jets collided mid-air at an air show at Ramstein, a a US airforce base in the former West Germany. One plane plunged into spectators, killing 45 people immediately, and injuring a further 700. Kossmann, then a trainee surgeon at a teaching hospital only 15 kilometres away, was on duty when, 90 minutes later, 47 critically injured and badly burnt people arrived. The scene, he recalls, was one of “unimaginable” horror, with so many victims with combined burns, shrapnel and blast injuries – the same ghastly combination he has been seeing again this week.
“Of those 47, 16 were in the same condition as the people we have at the Alfred now,” he says. “And of these, we lost five. There was at least one where we didn’t expect that he would die. The others were critical, with up to 90 per cent (of their bodies) burnt.”
Many were able to talk when they arrived at the hospital, which made their later lapses into unconsciousness – and the deaths – even more upsetting for staff.
The arrival of the Bali victims has brought all the horrific memories back.
“It is the same smell, the same physical smell of the patients,” he says. “It is a very specific smell of burnt flesh. And it’s the same circumstances with the relatives. They are very distressed.”
His Ramstein experience, says Kossmann, makes him feel confident of giving better advice to relatives. In particular, he tells them not to “burn out their batteries” too early. Relatives tend to be hyperactive, he says.
“It makes no sense for eight or 10 of them to be here and to have sleepless nights on a couch in the hospital when you can do nothing. They will be needed afterwards. The most difficult phase, for the patient, is not at the moment. It will come later, when the support from the media and relatives and friends is slowing down.
“It is important (for relatives) to be there when the patient wakes up. There is a very important phase when the patient goes to rehab. Even more important is when they come home from rehab, because normally no one is at home. Everybody goes to work, and the media isn’t interested any more.”
Kossmann also worries about the potential lung damage to his patients caused by inhalation injuries. “Toxic fumes might have burnt the lungs. We just don’t know this at this point.”
Rehabilitation from burns can take years.
“Some will heal well from their injuries, but it will be a long process before the soul is healed.
“If somebody has a burnt face, he will be a different person. If someone has lost a limb, his life has changed. Even if we can repair them, they will be different people.”
The experience of watching patients die is traumatic for staff, too. Counselling is already being offered to Alfred staff, but not forced on them.
“(In Germany) psychologically the staff felt betrayed by the patient when he or she died, because they were making so much effort. And it was seen as a decision, which was unfair to the staff. You know: ‘It’s unfair. I am caring for you. For the last three days my whole heart is with you – and you die.”‘
7.55am: The daily 30-minute X-ray meeting is drawing to a close. It is a meeting that must go on, Kossmann says, regardless of what else is happening in the hospital. The Alfred’s six Bali burns patients are on every front page and in every news bulletin. Even so, the surgeon must also find time for the other 32 patients in the trauma unit.
8.05am: Hotly pursued by a group of colleagues, registrars and students, Kossmann strides off on his ward rounds . He moves at a tremendous clip, his white coat flying out behind him. His first stop is the intensive care unit where trolleys stand stacked high with dressings and instruments. Each green-curtained cubicle houses a patient hooked up to a small electronic forest of monitoring equipment. There are respirators and machines measuring heart and lung function and blood pressure. Devices monitor the infusion of fluids and medications. Gloved and aproned nurses, one per patient, move smoothly around their charges, gently raising a bandaged hand from a pillow over here, checking the flow of liquid through a tube over there.
One of the Bali patients is being wheeled off to surgery for debridement and skin grafts as Kossmann arrives.
“All the best, see you later,” he says. The patient raises a weary salute by way of reply.
The condition of the burns patient in the next cubicle has deteriorated in the past 12 hours. Yesterday he was reading the paper. Today he’s breathing with the aid of a ventilating machine. “Have his relatives been informed?” the trauma unit director wants to know. The patient will “make it”, he says. But it’s important that the families know exactly what’s going on.
Lay people, he says, misunderstand burns.
“One of the surprises (for them) is that many of these patients were walking round, and they initially thought that their problems weren’t great. Some of them walked on to the plane, but then they just deteriorate due to the fact that they have this infection, they have not been resuscitated in the right way, they are starting to have organ failure.
“Also with third-degree burns you don’t feel pain because the ends of the nerves are just dead, so they don’t function.”
The Bali victims missed the “golden hour”, Kossmann explains – the first hour after injury when medical intervention is needed most. The best possible outcome would have been immediate treatment with fluids, bandaging and pain relief.
“Pain is a stimulant and you need to calm the body down. And if you don’t have enough body fluids, your organs are not sufficiently suffused with blood.”
Part of the assault on the burns victims’ bodies comes from outside. “Our skin is the highly developed protection barrier against all this bacteria which would harm our body. You breach this barrier and suddenly everything can come in.” With the warm temperature in Bali, the burn surface becomes the ideal “microbiological chamber” for bacteria growth. With body fluids exposed, the bacteria can multiply quickly. But organ failures are also a result of the toxins produced by the body itself in its fight against the massive insult of burn injuries.
“Our evolution never foresaw that we would survive burns. Our defence mechanism is not sufficient – and the toxins, the bacteria are just taking over. The body has to discharge them through the kidney and the liver and the strain on organs is too great.”
Most of the other cubicles in intensive care are occupied by road accident victims. The driver of a car who went into a tree. The survivor of a head-on collision. Each cubicle reveals a new tragedy – like the woman who was attacked with a stool, one leg of which has penetrated her brain.
8.30am: Kossmann gallops up a flight of stairs to the hospital’s second intensive care unit. After a quick conference with the burns unit boss Heather Cleland about skin grafts for one Bali victim, he moves on to check another blast victim. “He is starting to get cold,” he murmurs to a colleague. “There’s a zoo of organisms growing on his back,” mutters another doctor.
This unit has the same preponderance of road accident victims as the one downstairs.
“The day we took the six Bali patients, we took in another eight local victims,” says the hospital’s trauma coordinator Louise Niggemeyer, one of group of 12 colleagues following Dr Kossmann on his round.
9.45am: He pauses for a brief chat with Dr Stephen Salerno, from the hospital’s medical services department. He wants to line up a theatre for a debridement operation he needs to perform on a burns victim, before Cleland carries out some skin grafts on the same patient.
Kossmann is also worried about a possible serious infection inside another patient’s belly. “We will do a laparoscopy (a procedure in which the smallest possible cut is made, so a mini-telescope can look inside the body). He has ongoing infections so we have to see what’s there. If there’s nothing, we don’t open it. If there is something, we will open it. You have to always figure out what is beneficial for this patient. Is it beneficial to have the risk of laparoscopy, or do we wait until he is so sick that he might die. We are always on a very small pathway – what is the best for the patient.”
Another Bali patient is having another head CT scan. “Just to check the head, to see if there is a change. If we don’t address this, we have a huge problem.
“With all these patients, we are a little bit behind (because of their lack of immediate care in the initial hours). We want to stay one step ahead of the complications.”
Some of the Bali patients will also have sessions in the hospital’s hyperbaric chamber, because it is believed that the enhanced oxygen levels in the tissue help healing of difficult open wounds.
10.40am: In the sixth floor burns unit Kossmann shares a joke about bowel movements with one Bali victim, checks another and then heads downstairs for a brief visit to the trauma out-patient’s clinic.
“Trauma patients are so highly motivated,” says the surgeon, who originally planned to specialise in plastic surgery until he did a stint as a trauma unit nurse and found himself captivated by the variety of the work.
“I saw you on telly last night,” says one outpatient. “You looked great.” Kossmann looks uncomfortable.
11.20am: The surgeon makes a flying visit to the Australian Orthopoedic Association conference. He would have been there every day in a normal week.
1.10pm: Back in the hospital, he is talking on his mobile in Italian. It’s his wife, Cristina Morganti-Kossmann, a neuroscientist and acquired brain injury expert, who’s in the cafeteria with two other colleagues. The couple came to the Alfred as “a package deal”, which involved them moving their previously Zurich-based acquired brain injury research program to Melbourne.
1.20pm: Cristina Morganti-Kossmann is sitting with trauma care coordinator Michelle Srage, who spent Monday organising a major clear-out of trauma unit patients, to make room for an expected influx of 10 or 11 critically ill Bali blast victims.
“Every family has been given a social worker,” she says. “Theatre staff allowed me to take one victim’s mother into the theatre so she could see her son (who had just arrived from Darwin) before they put him to sleep. That never normally happens in an adult setting.”
2.30pm: Kossmann is in the second-floor intensive care unit to meet Dick Gleason, father of the Canadian burns victim Richard Gleason. Dick has come straight from the airport after the long journey from Whitehorse, a small town in the Yukon district of Canada. His ex-wife will be arriving in the next day or so. Kossmann takes the worried father into the cubicle where his heavily bandaged son is lying, and begins to explain the operation, a laparoscopy, that will take place soon.
2.55pm: Kossmann is scrubbing up for a spinal fusion operation on an elderly man who has had a bad fall. He’s sharing the operation – a delicate and tricky procedure – with consultant neurosurgeon Greg Malham. A bone graft is being done with bone from the hip, so the theatre fills with the typical orthopoedic surgery sounds of bones being hammered and sanded down.
4.10pm: Back in the operating theatre suite’s office, he checks Friday morning’s theatre schedule. His operation on one of the Bali victims is booked in for the morning and burns unit boss Heather Cleland will follow with her skin grafts.
4.15pm: Richard Gleason is wheeled past on a trolley on his way to theatre. Cleland, in her blue operating scrubs, is taking a quick breather between two surgery sessions.
4.25pm: Out of his scrubs and back in his suit, Kossmann makes another quick round of the two intensive care wards. An anxious relative stops him on the way in. “I’m told you’re the best in the world,” she says.
In one cubicle, a Bali burns patient’s face is covered in a special foil-look dressing. “To avoid bacterial colonisation,” Kossmann explains.
6pm: He leaves the hospital to go home and dress for a black tie dinner for the Orthopedics Association conference. How long will he last? “Until dessert,” he says wearily. “I’ll drink water only.” Of course he’ll have his phone and pager with him. It wouldn’t be the first time he’d turned up at the hospital in black tie for a late-night check. And he’ll be on call from Friday morning until Saturday at 6pm.
6.15pm: Dick Gleason is sitting on a bench in the foyer. He’s just had the results of his son’s laparoscopy procedure. It’s good news. His son’s internal organs are OK. There is no need for surgery on his bowel.
He sighs. “It’s just another ordeal he doesn’t have to experience.
“I’m less worried than I’ve been since last Sunday. This will be very tough on his mother. I was in Korea, and I’ve worked in the ambulance service. I know about burns. But it’s different when it’s my own son. It’s shocking. It rips you apart.”
BALI VICTIMS AT THE ALFRED
• Jason McCartney, 28, has extensive burns. He is in intensive care.
• Lynley Huguenin, 22, of Wantirna. She is in a stable condition.
• Jodie Cearns, 35, has burns to 55 per cent of her body and shrapnel wounds to her stomach. She has had her left leg amputated above the knee, may have lost sight in her right eye, and her right leg and pelvis are broken.
• Dale Atkin, 27, of Hallam, is in a stable condition.
• A Victorian man whose name has not been released.
• Richard Gleason, a 38-year-old Canadian is in intensive care with burns to 50 per cent of his body.

My friend working at a university in Melbourne somehow got a hold of Rick’s mom on my behalf and talked to her. An exerpt: […] “He is covered in bandages from head to foot. He is unconscious and has been since arrival in Australia. The doctors are keeping him unconscious whilst they perform skin graft surgery. He has already undergone 4 operations. Once he regains consciousness an assessment of brain damage can be made. His chances of survival are better than when he was first airlifted to Melbourne, but remain 50-50. The danger now is from septic complications and the failure of stressed organs.”
Also, you probably know but according to my friend, the Royal Alfred Hospital has the best burns unit in Australia. According to Ian, Rick’s mother is very happy with the treatment he is getting.
I guess they are getting inundated with a lot of inquiries, so she also told my friend (Ian) to use Jamie [Gleason, Rick’s brother] as a point of contact […]