Medical consequences of suicide bombing mass casualty incidents: The impact of explosion setting on injury patterns
Introduction
Suicide bombing attacks against civilian population in urban settings have become frequent phenomenon in recent years. Many countries in Europe, North and South America, as well as the Middle East and Asia have experienced such events and are subjected to an ongoing threat. Some countries such as Israel, Russia, India and Spain have been affected by repeated attacks over many years. In Israel, the most frequent site of suicide bombings in the past decade, hundreds of civilians have lost their lives and thousands of others were wounded as a consequence of these actions.
Suicide bombings often entail a high rate of blast and penetrating injuries to a large and a diverse group of victims. This type of attack involves characteristic features of both, military and civilian trauma. Urban civilian trauma differs from military trauma in several ways. In civilian trauma, there is a high prevalence of blunt trauma and the time of evacuation is relatively short, while in military casualties, penetrating trauma predominates, and the time of evacuation is considerably longer. In addition, military casualties are quite homogenous, consisting mainly of young, healthy people while, in the civilian milieu, the endangered population tends to be much more varied.2, 5, 6, 8, 9, 10, 11 The injured often include women, children, and seniors, who may suffer from other medical co-morbidities and low physiological reserves. Therefore, neither “civilian” nor “military” medical doctrines are satisfactory, and a modified approach should be implemented.
Suicide bombings pose a major challenge to Emergency Medical Systems (EMS) and hospitals across the globe. Their complexity derives from the high number of casualties with various injury severities and medical needs, all encountered in a very short period of time. The medical system main goal is to identify and properly treat those casualties who are critical but salvageable, yet provide other casualties with an acceptable level of care. A detailed learning of these events may result in better understanding of these complex situations and a higher level of preparedness.
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Materials and methods
Pre-hospital and in-hospital data was collected from 903 casualties injured in 12 consecutive multiple casualty incidents (MCI's) caused by suicide bombings in a civilian setting. These events occurred between March 2002 and January 2003. Pre-hospital data was retrieved from the Israeli Emergency Medical Service operation centre recordings and debriefings. Full scale EMS data was available for 10 out of 12 incidents involving 818 of the casualties. Data included the times of the first
General
There were five bus explosions (BE) with a total of 264 casualties (average 52.8 ± 23.8, range 22–84). Three explosions occurred in closed spaces (CSE) with a total of 308 casualties (average 102.7 ± 56.5, range 58–156). Four explosions occurred in an open space (OSE) with a total of 331 casualties (average 82.8 ± 50.7, range 47–164). The most severe BE resulted in 17 deaths and 60 casualties. The highest number of casualties in an OSE, 156 individuals, occurred when two bombers exploded
OR surgical interventions
Surgical procedures were performed in 114 patients (Table 7). The highest rate of interventions (17.6%) was needed post-CSE. In all three suicide bombing settings, orthopaedic surgical procedures (Table 7) were the most commonly performed (9.4%, 9.6% and 9.8%, for BE, CSE and OSE, respectively). The high frequency of orthopaedic surgical procedures was statistically significant in comparison to all other operative procedures aside from the incidence of laparotomies in CSE. In this direct
Discussion
This study presents an integrative analysis of both pre-hospital and in-hospital data regarding the immediate medical consequences related to suicide bomb attacks in a civilian setting. Our data suggest that the physical setting in which the suicide bombings occurs, influences dramatically the pattern of injury, the casualties’ outcome and the associated impact on the health services. Since similar explosive devices were used in all the MCI's, the differences seen should be primarily attributed
Conclusions
Suicide bombing attacks in civilian settings result in multiple casualty incidents with an enormous challenge to both the Emergency Medical services and Hospital Systems. Proper preparation for these events mandates that the EMS will be able to concentrate large numbers of trained personnel and ambulances on scene in a very short period of time. These teams must operate under strict central control and adhere to clear triage protocols to allow attention to be directed to those critical
Conflict of interest
None of the authors or their relatives have received any financial or other sorts of support during the preparation of the study.
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