The ins and outs of terrorist bus explosions: Injury profiles of on-board explosions versus explosions occurring adjacent to a bus
Introduction
Over the past several decades the world has experienced a surge of terrorist attacks targeted towards civilians, which often result in mass casualty incidents (MCI). Victims of these terror attacks are susceptible to many of the various types of trauma injuries, thereby creating highly complex patterns of injury.1, 2, 3, 4 As each attack has been unique with regards to the type and weight of explosive, the setting, time of day, the targeted population, the crowdedness, and more, it has proved a challenging task to compare the injury patterns arising from the different attacks.5, 6, 7, 8 Further, injury characteristics of terrorist attacks differ significantly from common civilian trauma in that there are more penetrating and blast injuries following terrorist attacks.9, 10
Outdoor attacks have been shown to have different mortality rates and injury patterns from confined space explosions.11, 12, 13, 14, 15, 16 This has been attributed largely to the physics of a confined space explosion, in which the blast waves generated will deflect off a solid structure, thereby amplifying the lethal effect of the blast wave.17 Bus attacks are a curious occurrence given the composition of the bus and the density at which people are situated. Leibovici et al.18 found that explosions in buses had increased mortality rates, greater incidence of primary blast injuries, and caused more severe injuries among survivors than outdoor explosions. Kosashvili et al.21 examined outcomes from terrorist bomb explosions and found bus attacks to have higher immediate mortality rates, different injury severity distributions, and a different array of surgical procedures performed on victims as compared to explosions in indoor or outdoor settings.
What has been increasingly occurring are multitudes of attacks directed at civilian buses, and these attacks have occurred both within buses and adjacent to them. The literature commonly refers to all bus explosions as one situation, while in fact there may exist unique differences. To date there have been numerous papers describing injury patterns caused by explosions, yet there exist few large peer-reviewed studies describing injury patterns from terror explosions that occur within buses, nor has there been any comparison of terrorist explosions that have occurred within a bus or adjacent to a bus.
Because a blast wave is amplified in a confined space, we hypothesised that injuries would be more severe in explosions occurring within the bus. We hereby describe and compare the injury patterns associated with a series of 22 terrorist bombings in Israel involving buses that occurred between November 2000 and August 2004.
Section snippets
Materials and methods
Mass casualty incidents (MCI) resulting from terrorist explosions that occurred in and in vicinity to buses in Israel between November 2000 and August 2004 were reviewed. These dates span the period of the 2nd Intifada, during which Israel experienced a surge of terrorist attacks. Data were obtained from the Israel National Trauma Registry (ITR), maintained by Israel's National Center for Trauma and Emergency Medicine Research at the Gertner Institute for Epidemiology and Health Policy Research.
Results
We analysed 22 terrorist attacks targeted at civilian buses between November 2000 and August 2004. Sixteen of these explosions occurred within a bus (IB) and generated 171 victims, and six of these attacks occurred adjacent to a bus (AB) and generated 91 casualties. A total of 262 patients were admitted to the 10 trauma centres participating in the Israel National Trauma Registry.
ISS scores of the two patient populations can be seen in Fig. 1. The IB victims were significantly more severely
Discussion
The present study is the first to analyse the injury patterns among victims of terrorist explosions in which the bomb was detonated adjacent to a bus (AB). The characteristics were compared to terrorist attacks in which the bomb was detonated within the bus (IB). We found that IB victims were more severely injured and required more time-sensitive care than the AB cohort. The IB population required more intensive level care, had a greater percentage of severe chest injuries, and received more
Conflict of interest statement
The authors of this present study have no conflict of interest to report.
Acknowledgements
We would like to thank Limor Schwartz and the rest of our colleagues at the Gertner Institute for their assistance, as well as the Israel Trauma Group. We would also like to extend a special thank you to the Fulbright Program and the United States-Israel Educational Foundation for their support.
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Cited by (0)
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Israel Trauma Group: R. Alfici, J. Jeroukhimov, B. Kessel, Y. Klein, M. Michaelson, Y. Mintz, A. Rivkind, D. Soffer, D. Simon, G. Shaked, M. Stein, I. Waksman.