The central North Island's trauma system boss says there is a lot to be learned from the horror of the Whakaari/White Island eruption.
Dr Grant Christey is not only Waikato Hospital's trauma director, but also oversees the Midland network trauma system for the Bay of Plenty, Waikato, Hauora Tairāwhiti and Taranaki - a combined population of more than 930,000 people.
In Christey's view, there is a lot to be learned from "all the horror that we've seen done" since the Whakaari/White Island eruption.
"Something like this will happen again."
He said Midland would take a close look at the "horrible, horrible event" and the response, "to learn about how we can do it better in the future".
"Not just around the big centres - it can happen anywhere and we all need to be ready to have those smaller, totally dedicated hospitals ... [to] give them the plans and the resources to be able to deal with this.
"What happened at Whakatāne was quite spectacular," Christey said.
"They [patients] were packaged up and transported immediately which I think saved some lives."
He said Whakatāne Hospital used "innovative solutions" to deal with the influx of "terrible injuries" at almost "zero notice".
Staff ran out of ventilators and had to "handbag" patients instead: "Which means standing there breathing manually for the patients by squeezing a bag with a tube into the lungs."
Christey visited Whakatāne Hospital the weekend after the eruption to meet with staff.
He said they "switched into save mode" on December 9, when the volcano erupted with 47 visitors on it.
"There are so many heroes there you can't single anyone out."
He said many graduate nurses and doctors had been working at the hospital for just three weeks and some initially didn't know what to do.
"I think they should be really proud that they've just dealt with one of those events that may happen once in a lifetime."
Christey said the priority at Whakatāne Hospital was giving pain relief, which was "tough".
"Burns are extremely painful and one can only imagine what went on in the pre-hospital setting without good pain relief ... So they needed to have lines in place, intravenous access, which is challenging when someone's got a lot of burns."
All of the severely injured patients had to be intubated because they had "big facial burns or burns around the throat which can swell up later on and cause real trouble".
He said the trauma system would be working on improving its communications because at first, it was "a bit difficult".
"How do we answer those three questions that everyone wants to know which are: how many, how bad and when are they arriving?"
Eight patients in a critical condition were transferred from Waikato Hospital to Whakatāne.
Christey said this was a "huge" intake but "they got the same level of care that I would expect for any patient coming in ... on any particular day".
When a mass casualty response was declared at 3.25pm, the intensive care unit started readying beds, the rest of the hospital and operating theatres cleared operating space and staff were held back at work.
They aimed to process patients through the emergency department in 30 minutes - "a really big ask" that was achieved "with no fuss, no bother".
"It was almost silent in four very very busy trauma resuscitation bays."
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A doctor and nurse from outside of the emergency department were allocated to remain with each patient so they didn't get "lost in a busy system".
It wasn't just the patients' burns that were assessed.
"They could have had any internal injuries, chest injuries, abdominal injuries, liver, spleen and limb injuries because this was a blast type scenario as well as burns."
After the first few hours, the plastic surgeons got to work, starting with "rub downs".
"They washed all of the wounds and tidied everything up because the patients had a lot of ash and the wounds were really dirty."
Severe burns victims lose the ability to regulate their body temperature, so the operating theatres are heated to above 30C.
Five theatres worked through the night and operating teams were rotated to manage "the very resource-intensive burns cases".
Christey commended their stamina.
"They are very fatigued, being in a very hot environment."
So many surgeons from other wards and other hospitals gathered to help that first night, that a coffee room had to be set up.
Specialists were brought in from the room as required.
"Cardiothoracic surgeons, general surgeons, plastic surgeons, orthopaedics. We had so many people."
The health board contacted nearby medical care providers to get supplies they were running out of.
"Private hospitals gave graft materials, special dressings, any equipment the plastic surgical teams required."
Some elective operations, mainly in plastic surgery, have been cancelled to allow urgent burns operations to go ahead during the day time.
"These operations, on subsequent days, particularly skin grafting and what we call debridement [removal of dead, damaged and infected tissue] take many hours per case. So that's cut our ability to do electives."
He said the "amazing" Australian hospitals had taken a load off the New Zealanders by repatriating many patients.
Christey has been one of the liaison staff updating victims' families.
"They were fairly sombre conversations [when loved ones first arrived]. We tried to go for the positives but also be realistic that with burns, over 50 to 60 per cent, there's a really high rate of mortality.
"They want to know what's going on and make sure that they get the information ... even though there are some harsh realities in that."
Christey was confident appropriate support was available to those involved in the "very confronting and quite horrific" event across the Midland region.
"Whakatāne has got around these people as a community that's hurting ... They're paddling their own waka down there doing what they need to do, so we're all standing by ready to help."
Christey insisted he wasn't "anything special" and "just part of the team" in the response.
"Everyone just stepped up and got on with it. No drama," he said.
"I think, to be honest, there are a couple of things that we would have done differently but in the circumstances, I think we did an amazing job."
Whakatāne Hospital medical leader Dr Heike Hundemer told a press conference earlier what they were faced with on December 9 was "beyond comprehension" at the hospital of 110 beds.
An influx of 30 injured people arrived, most of whom had burns to more than 30 per cent of their body.
"I've never seen this number of critically injured patients coming into an emergency department in such a short space of time," she said and added that some victims were known by staff.
Normally the emergency department is run by six nurses and two doctors but the team grew to 100 when staff from Tauranga Hospital, nearby GPs, and unrostered staff arrived to help.
John Bonning, president of the Australasian College for Emergency Medicine, earlier said that as he wheeled patients into Waikato Hospital, he could smell the sulphur coming from their clothing and saw "bits of dead skin" and "broken ash" peeling off their bodies.
"Saying it was like a war zone would not be an understatement."
• Seventeen deaths have been confirmed.
• One person died last night in Middlemore Hospital and another died nine days ago at Waikato Hospital. Another person injured in the eruption and later repatriated to Australia, also died that day.
• Two people remain unaccounted for on or in the vicinity of Whakaari/White Island.
• Thirteen patients have been transferred to Australia.
• Eight patients are being treated at Middlemore Hospital, two at Waikato Hospital, two at Hutt Valley Hospital and one at Christchurch Hospital.
• Nine of those patients across the country are in critical condition.
Source: The Ministry of Health
Audrey Wilson had repeated falls, a fractured arm and sepsis. She died in hospital.