John Pearn, a former surgeon-general of the Australian Defence Force and now professor of paediatrics at Brisbane's Royal Children's Hospital, said that given the conditions in the tsunami-hit areas, large numbers of amputations were unavoidable.

"We can expect relatively large numbers of amputations where wounds still are contaminated with foreign bodies and where infection has led to dead tissue or gas gangrene," he said.

"Under these conditions, a disproportionately large percentage will require amputation."

He said this would also create other problems, such as the need for proper medical stump care and the manufacture and distribution of large numbers of prosthetic limbs to help rehabilitation.

Late yesterday, a group of survivors, some having only hours earlier lost their gangrenous limbs, were placed on a rickety truck and driven a torturous 15km to Banda Aceh airfield. None had been given much pain relief over the past few days.

The Australian doctors who performed the amputations had only enough anaesthetic for surgery. The ward staff have little morphine to spare.

So far the world has not been able to deliver to Indonesia's refugees what they need most -- a way to reduce their pain. The two operating hospitals, and military medical points in Banda Aceh are near breaking point.

"What we did was against our basic training," said Singapore surgeon Francis Seow-Choen, one of the first foreign doctors to arrive in the province.

"There was no sterility. We were using the same instruments on different patients. But all of us knew we had to do it or the patients would die."

All around Banda Aceh's medieval hospital wards, there are people without limbs. The numbers of amputees have been growing sharply by the day as refugees with gangrene and other chronic infections finally seek out medical treatment.

Many have made their way overland on treks of up to 160km. Some have been airlifted by the US Navy. So serious are the wounds of many patients that doctors simply have no option but to amputate their infected limbs.

Even with the contribution of medics, anti-disease specialists and logistics staff from 21 countries, authorities here were not prepared for such large numbers of injured and their chronic wounds.

The extent of the number injured is still not known, with forward medical teams only being established in the hardest hit ocean-front villages on Monday.

The first was a Singaporean defence medical team, which set up in the largest west coast town of Meulaboh. Surgeons there reported filthy conditions and desperate shortages of sterilised equipment.

There is not yet a credible account of the plight of the surviving locals, with many having stayed in the hills since the tsunami.

In Banda Aceh's Fakimih Hospital, where an Australian medical and rescue team is based, the corridors are lined with people with broken limbs and chronic infections.

The smell of infection permeates the wards, with gangrene and tetanus seen as the biggest threats to life. Yesterday, 100 patients with such infections were evacuated to the north Sumatran city of Medan on board a US air force Hercules.

Infectious diseases specialist Jeremy McAnulty, from NSW Health, said there had been outbreaks of dysentery at some refugee camps near Banda Aceh, but so far no confirmed cases of cholera.

"That may change when we get a better feel for what's happening on the west coast," he said.

Few Indonesians are inoculated against either tetanus, cholera or malaria. Cholera is most likely to breed in waterways infected by sewage, or corpses, precisely the conditions seen across Aceh 10 days after the tsunami.

The Australian Defence Force hopes late this week to reopen a public hospital that took a direct hit from the giant wave and still lies encased in a metre of mud.

But scores of bodies, many of them children, are thought to litter the pediatric ward.  (Source...)