Jane Perlez, Banda Aceh – In the makeshift recovery room, Dr. Paul Shumack crouched on the floor cradling the head of Novi, 35, who had already lost her husband and only child to the tsunami, and now her right leg.
The doctor had just amputated it to the buttock. Short of supplies, the surgical team had been forced to use what was described as a handsaw.
The hour-long operation drained huge amounts of blood from Mrs. Novi, already weak from asthma. There was no blood for a transfusion. Her fingers were turning white.
"She is dying," said Dr. Shumack, the leader of an emergency surgical team of Australian doctors and nurses. Ten minutes later, still holding her head, he softly pronounced her dead. "We gave her what chance we could."
International health officials have warned of soaring numbers of casualties among survivors of the tsunami 10 days ago, but doctors here say that many of the most seriously injured died even before medical teams arrived here near the center of the devastation.
"To some extent a process of natural selection has occurred," Dr. Shumack said. "People with no treatment at all are already dead."
Those at gravest risk now are people like Mrs. Novi, who suffered relatively minor injuries and could have been more easily saved if she had received emergency medical care last week. There is little way to know precisely how many people like her are now dying, but doctors say time is running out.
After days of trying to save grossly infected limbs at the poorly supplied military hospital here, Dr. Shumack and others have increasingly resorted to amputation, in the hope of saving lives. The number of amputations suddenly climbed this week, he said.
On Wednesday, four of the nine patients who went through surgery had legs amputated, a last resort that the doctors said they knew spelled a hopeless future in land lacking crutches, let alone prosthetics.
The seawater that swamped the city consisted of a foul mixture of sanitation waste, garbage and debris. Many of those who did not drown were cut by flying bits of trees, wood and metal. Even for the injured who managed to scrounge a few dabs of antiseptic and a bandage at chaotic camps, wounds have become seriously infected, in many cases septic.
"A couple of drops of this putrid water gives these people rip-roaring pneumonia and lacerations that get horrendously infected," Dr. Shumack said. "The septicemia is incredible. The surgical cases have become more complicated because the infections are becoming more spectacular."
For the last two days, Zaini, 60, a scrawny fisherman and the only survivor in his family, had refused doctors' explanations that the only way he could survive was to have his left leg cut off below the knee. He had wandered dazed and alone after the tsunami. Like many, he had suffered deep cuts that had not been cleaned. His left foot and calf were hugely swollen. The doctors deemed the lower leg "100 percent infected."
During a round of the hospital's overflowing wards on Wednesday morning, when the doctors picked out those they thought would most benefit from surgery, Mr. Zaini insisted that he only wanted his gashed leg cleaned and dressed. "He has no chance unless there is an amputation," said Rene Zwellinger, the head of the emergency trauma unit at the Perth Royal Hospital in Australia.
Mr. Zaini was brought to the pre-operation room anyway. He weighed about 95 pounds. His face was covered with fear. The doctors asked a translator, Rusma Mohammed, to explain his options one more time. "If you have the amputation you will have a chance to live," Mr. Rusma told him. "If you do not, you will die."
Finally, Mr. Zaini agreed. But after the operation the doctors were still doubtful about his chances. "If he survives the next 12 hours, he's likely to survive," said Dr. Paul Luckin, the attending anesthesiologist.
Much of the doctors' work on Wednesday was to save remnants of families. Of the nine men, women and teenagers they operated on this day, almost all had lost most of their family members.
Just before noon, a brother and sister, Joni, 27, and Sulayani, 13, were on the two operating tables having deeply infected leg wounds cleaned. The other 10 members of their family had died, they told the doctors.
Ms. Sulayani, a pretty girl with a brave smile and dressed in neatly pressed pink pajamas, had a deep wound about the size of a tennis ball on her lower left leg. The doctors had her carried into the operating room just as her brother's operation was finishing.
"If this had been treated eight days ago, it wouldn't be a problem," Dr. Zwellinger said as he carefully peeled back the layers of skin to remove pus. The infection had gone to the muscle but had stopped short of the bone.
Even so, she underwent what the doctors called radical surgery for what they believed had initially been a relatively small laceration. "Small wounds have been left so long they end up being big wounds," said David Scott, an Australian anesthesiologist, as he worked on Ms. Sulayani's leg.
In time she would need a skin graft, which might be done by an American team of doctors from the aircraft carrier Abraham Lincoln, who were expected to begin work within a few days. The prospects for the girl were good if she got the skin graft, the Australian team said.
"She's healthy now and was very healthy before the tsunami," said Dr. Scott. "This is a normal kid. She's like the kid next door. She should be at school."
But for others amputation was unavoidable. Khatijah, 40, who said she had been tossed around in the raging tsunami water for 10 hours, lost her husband and only daughter.
Her son, Gunaidi Rusli, 25, said he borrowed his boss's motorcycle and managed to get his mother to the hospital. She understood, he said, that her right leg had to be amputated below the knee. But she was most worried about a serious infection on her lower right arm. Under no circumstances did she want that lower arm cut off. "We must absolutely save her right arm," Dr. Zwellinger assured her son.
Afterward the doctor said that the amputation of the lower leg had proceeded well but that the right arm was "still a big problem." In order to ensure that it would heal, the surgeon said, Mrs. Khatijah would be evacuated to a hospital in Medan, a city to the southeast where the prospects for keeping the wound clean were much better. "The Australian Air Force will take her to Medan very soon, we hope tomorrow," Dr. Shumack told Mr. Rusli. "How much will it cost?" he asked. "It will be free," the doctor answered to Mr. Rusli's evident astonishment.
The working conditions for the team of volunteer doctors, who were organized by the Australian government and went into action on Thursday, were far from ideal.
At one point on Wednesday, the electricity sputtered out; they continued to operate with flashlights. They brought 39,000 pounds of surgical equipment but by the time they did their first amputation on Wednesday, they realized they had run out of a special amputation saw, known as a Gigli, which allows doctors to cut through bone with minimal damage to muscle and other tissues.
They had brought only four, and although the saws are too fragile to bear much re-use, the doctors had managed it a few times in the past few days. Now they had run out.
The operation on Mrs. Novi was delayed as an Australian doctor hunted in the military hospital's storeroom. Eventually, Dr. Luckin said, they found what he called a handsaw.
Even simple things were difficult, like transportation from their living quarters, at the only other functioning Acehnese hospital. Two days ago the medical team flagged down a garbage truck and stood in the back of its trailer for their trip to work.
But the hardest thing on Wednesday, Dr. Shumack said, was the death of Mrs. Novi. On a piece of paper, with a black marker, he wrote: Novi 13:30 January 5, 2005 and tucked it into the body bag.
A little later, her sister asked four hospital volunteers to carry Mrs. Novi's body to a tiny jeep – so small that the end of the white body bag trailed out the rear door on its way to burial.