Bali bomb lessons helped shape mental health response to terrorism and trauma

Staff at the Royal Darwin Hospital – who treated many of the casualties – also received vital personal support from mental health nurses, especially as they waited anxiously for the first victims to arrive.

“The 2002 bombings were Australia’s first large-scale introduction to terrorist activity in the immediate geographical area and they initiated a new phase of trauma response for public health services in the country” says Anthony Guscott of Top End Mental Health Services, which provides in-patient and consultation liaison nursing services at the Royal Darwin Hospital.

“A national mental health response to mass trauma was established and this proved particularly useful to the Royal Darwin Hospital, which handled a large number of casualties from both bombings.”

The national group driving the national mental health guidance were also able to draw on their experiences of other traumatic events, including the Eyre Peninsula bushfires that killed nine people and injured 110 in South Australia in January 2005.

This national guidance was then used to shape more effective local front line mental health services to cover both day-to-day needs and cope with major incidents. For example, the Royal Darwin Hospital now has a round-the-clock mental health presence in the emergency department and other departments can call on out-of-hours’ support as needed.

Many of the bomb victims suffered profound mental health problems immediately after the bombings. In 2002 the mental health response was poorly planned, but the lessons learnt from the first incident meant that in 2005 patients’ physical and mental health needs were better co-ordinated by staff who had already recognised and established a stronger link between trauma and psychiatric support.

Just over 200 people were killed by the 2002 bombs, including 88 Australians, and hundreds more suffered burns and other injuries. Many of the victims injured in the suicide bombings at Paddy’s Bar and the Sari Club in Kuta were taken to the Royal Darwin Hospital to be stabilised before being moved to other hospitals. A high proportion had suffered chemical burns.

A senior psychiatrist and the director of mental health nursing were available to provide advice, but no psychiatric reviews were requested by staff who treated the victims or prepared them for transfer to hospitals in their home states.

The experience in 2005 was very different.

Twenty people were killed and 129 wounded in the bombings in October 2005 – four Australians died and 19 were injured. On this occasion the majority of deaths and injuries were caused by shrapnel rather than burns.

Top End Mental Health Services’ staff were involved in the trauma planning sessions as soon as word of the bombings reached the hospital.

The experienced mental health nurses who had previously worked with people affected by the Eyre Peninsula bushfires provided a high profile presence in the emergency department, for patients and staff alike, from the moment casualties were admitted. And all patients underwent a mental health review before being moved to hospitals in their home states.

“Staff saw victims who had severe shrapnel wounds and were physically and emotionally affected by the bombings” says Guscott.

“They experienced depersonalisation, disassociation, disbelief and anger. Many described greater physical pain than their injuries would be expected to cause, together with a physical ache over their losses, thoughts of what could have been and the futility of the situation.

“All spoke in their own ways of how they felt their safety and personal space had been violated.”

And because the 2005 bombs were detonated at dinner time, some victims found it difficult to eat and became anxious at mealtimes.

The early intervention by mental health nurses proved invaluable for many of the patients.

In a short period many changed from providing limited verbal responses to starting to communicate more confidently.

The mental health nurses also provided vital, confidential support for other hospital healthcare staff while they were waiting for the victims to arrive and ongoing support while they treated them.

“Some staff described the eeriness of the ward waiting to receive incoming patients and other were anxious about what to expect having been involved in caring for bomb victims three years earlier” says Guscott. “And a number of general nurses and support staff also experienced disturbing phenomena such as the smell of burning flesh – a throwback to the chemical burn victims treated by the hospital in 2002.”

Following the 2005 incident hospital staff also took part in feedback sessions run by mental health staff so that their comments could be used to make any further improvements to the major incident plan and identify any ongoing staff support that was needed.

Guscott doubts whether the Royal Darwin would have handled the second bombing as effectively without the lessons learnt from the first.

“The fact that mental health nurses had become a recognised part of the hospital establishment between the two incidents meant that staff worked together in a much more co-ordinated way to help the victims of the second bombing” he says. “They also recognised that the mental health nurses could provide them with the support they needed to handle the trauma.”