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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 122-126

An audit of emergency response to terrorist-related bomb blasts and gunshot injuries: The experience of a low-resource care center in Northern Nigeria


1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bayero University Kano, Nigeria/Aminu kano Teaching Hospital, Nigeria
2 Department of Community Medicine, Faculty of Clinical Sciences, Bayero University Kano/Aminu Kano Teaching Hospital, Nigeria
3 Department of Surgery, Bayero University Kano, Nigeria/Aminu kano Teaching Hospital, Nigeria
4 Department of Surgery, Bayero University Kano, Nigeria/Aminu kano Teaching Hospital, Kano, Nigeria
5 Bayero University, Kano, Nigeria
6 College of Medicine University of Florida, Gainesville, Florida, USA

Date of Submission18-Aug-2021
Date of Decision28-Aug-2021
Date of Acceptance23-Oct-2021
Date of Web Publication10-Dec-2021

Correspondence Address:
Dr. Taiwo Amole
Department of Community Medicine, Faculty of Clinical Sciences, Bayero University Kano/Aminu Kano Teaching Hospital
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_40_21

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  Abstract 


Context: The management of mass casualty events caused by terrorist-related suicide bombings in densely populated areas is often challenging. Aims: This study describes the pattern of injuries, the emergency response following a suicide bombing in Nigeria in 2014 and compares the outcomes to those of other incidents. Settings and Design: A retrospective analysis of cases that presented to a major tertiary care center was done. Methods and Material: Medical records of 50 patients who experienced bomb blast or gunshot wounds during 28th November, 2014 suicide bombing of the Kano Central Mosque were reviewed and 12 eyewitnesses were interviewed. Statistical analysis used: Descriptive analysis of quantitative data was done while major themes were identified from the key informant interviews. Results: Fifty patients were admitted at the acute care center within 4 hours. There was a male predilection (98%), with a median age of 30 years (IQR, interquartile range = 37.5 years). Most injuries were the result of multiple penetrating projectiles (secondary blast injuries), primarily involving blast-energized metallic fragments like screws, nails, bolts, ball bearings, and metal scraps. Eleven patients (22%) had minor lacerations, about a quarter (n = 12; 24%) had severe hemorrhage and were transfused, five (10%) had multi-system involvement, and mortality rate was 8% (n = 4). Interventions were aimed at preserving the lives of those injured. Conclusion: Most of the victims had major injuries which were appropriately managed although the hospital lacked an existing protocol on mass casualty management. Increased awareness, organized field triage mechanisms, and capacity building in health facilities will facilitate prompt emergency response.

Keywords: Bomb blasts, mass casualty, polytrauma, triage


How to cite this article:
Amole O, Amole T, Omeje K, Efunkoya A, Osunde O, Muhammad MA, Aji SA, Ismail H, Abubakar M, Akinlade A, Ahmed R, Becker T. An audit of emergency response to terrorist-related bomb blasts and gunshot injuries: The experience of a low-resource care center in Northern Nigeria. Niger J Basic Clin Sci 2021;18:122-6

How to cite this URL:
Amole O, Amole T, Omeje K, Efunkoya A, Osunde O, Muhammad MA, Aji SA, Ismail H, Abubakar M, Akinlade A, Ahmed R, Becker T. An audit of emergency response to terrorist-related bomb blasts and gunshot injuries: The experience of a low-resource care center in Northern Nigeria. Niger J Basic Clin Sci [serial online] 2021 [cited 2022 Jun 25];18:122-6. Available from: https://www.njbcs.net/text.asp?2021/18/2/122/332195




  Introduction Top


The incidence of terrorist-related suicide bombings using improvised explosive devices (IEDs) directed at civilians in the some parts of Nigeria has increased. This is connected to the armed insurgency originating from North-Eastern Nigeria.[1] IEDs cause injuries similar to those seen during military conflict,[2],[3],[4] which do not fall within the scope of the daily routine of the hospital's acute care staff. Mass casualty incidents (MCI) frequently overwhelm local resources due to the number and severity of injuries.[2],[3]

Basic principles of MCI management involve on-site or field triage, resuscitation, transportation, hospital triage, immediate and continued management.[5] Usually the surge capacity, which refers to a measurable representation of an acute care unit's ability to manage a sudden influx of patients, is exceeded. Advanced planning and disaster preparedness can ensure a coordinated response with optimal use of personnel and scarce resources.[5],[6] Suicide bombings relatively new occurrences in the Nigerian environment and as such, there is a dearth of knowledge on injury pattern, triage, and acute management in MCI from IEDs.[5]


  Subjects and Methods Top


On the 28th of November 2014 at 2:30 pm local time (1:30 GMT), a suicide bombing using an IED occurred in Kano Central Mosque. Casualties were transported to three different hospitals, including two district hospitals and the study center which is Aminu Kano Teaching Hospital. Our facility is an 800-bed tertiary care center equipped with 16 theater units, four adult and one pediatric intensive care unit (ICU). All major surgical specialty services are available. The hospital is equipped with diagnostic facilities including laboratory and imaging (plain radiographs and computerized tomography). The center is affiliated with both medical and nursing schools. It is the most equipped acute trauma care facility within the region and serves as the main referral center to the two other regional centers as well as to the hospitals in six states in the northwestern region of Nigeria. The two district hospitals are secondary health facilities and are geographically closer to the site of the MCI, 1 km and 5 km, respectively, than our center which is located 14 km away.

We retrieved information such as socio-demographics, means of transport from the MCI site, on-site field triage/in-transit interventions, Glasgow coma score, pattern of injuries on clinical and radiological examination, and the clinical interventions provided. Other sources of clinical information included conscious patients and relatives, case notes, emergency/theater registers, and nurses' daily report book.

The collected data were subjected to descriptive analysis using SPSS version 20. Frequencies and percentages were used for qualitative variables and mean standard deviation for quantitative variables.

Twelve subjects who were not affected but were witnesses to the event and participants in the subsequent rescue attempts were interviewed as key informants. A key informant interview (KII) guide was designed and used to collect information on details before the attack, during, and immediately after the event, the nature of response at the site. The details gathered were further corroborated by online research. Social media platforms (Twitter and Facebook) and newspapers online (This day, Daily Trust, Triumph, and Guardian) were used.


  Results Top


Patient characteristics and hospital response

A total of 50 patients from this MCI event were triaged at the hospital acute care unit and those that required subsequent admission were managed in a dedicated 4 block ward with a total capacity of 60 beds.

Key informant interviews

Account of the explosions

There were three explosions at the worship center occurring within seconds of one another. One IED exploded within the premises of the mosque, another within the building itself, and a suicide “car-bomb” exploded outside the premises in a coordinated suicide attack. This was followed by sporadic exchange of gunfire between law enforcement agents and the terrorists, causing more injuries from bullets and stampede from fleeing worshippers. The first responders after the gunshots and blasts had ceased were the police, the military, civil defense corps officers, relatives of victims, and bystanders. No pre-hospital/on-site triage was recorded as all patients who were seen to be alive, bleeding, prostrate, or requesting for help were rushed to the nearest hospitals by first responders. Victims were initially rushed to two closest district hospitals. The patients who were brought to our center arrived about an hour after the terrorist attack, presumably because the two district hospitals exceeded their capacity or the severity of the injury was beyond their expertise. Transportation of the wounded and the dead was done using some of the few private ambulances, police/military vehicles, and private cars.

Disaster response

This event happened within a period when all unions of hospital workers, excluding the doctors, had embarked upon a 2-month “strike” in which they stayed off work to express some grievances to the government. The hospital at this time had no existing protocol for managing mass casualties. An hour after the MCI event, an initial surge of 37 patients were rushed into the acute care unit of the hospital which was converted to an in-hospital triage zone. Thirteen (additional patients were brought in afterwards as they were referred from other district hospitals. A prior alert had been given to the hospital management through a phone call. The unions announced that they would temporarily suspend their strike to care for the injured patients. There was no standardized mass casualty notification system. The head surgeon of the hospital acted as incident commander; communication broadcasts were sent via a hospital-based personnel list serve to all doctors, head nurses, and laboratory and blood-bank personnel. The phases of care included in-hospital triage, acute care, followed by admission for definitive care.

The population of physicians and other clinicians who responded included orthopedic and trauma surgeons, general surgeons, urologists, neurosurgeons, plastic/maxillofacial surgeons, ENT (ear, nose, and throat), pediatric surgeons, general medical practitioners, anesthetists, anesthetic nurses, pediatricians, dentists, and medical students. In-hospital triage was done by a team of surgeons using external injuries severity (anatomical) as guide and radiographs when needed were taken by moving the patient to the emergency imaging rooms attached to the emergency unit. The commander was responsible for tasks allocation based on competence of available personnel. Surgeons and anesthetists were distributed to the four available in-hospital operating rooms (OR) and triaged patients were sent to the appropriate OR based on the competencies of the surgeons there. General medical practitioners and medical students assisted during triage in securing intravenous access, control of hemorrhage, and other aspects of resuscitation.

Requirement for blood transfusion was overwhelming and patients were treated with crystalloids, colloids, or transfused with uncross matched but group type blood when necessary. There was no crowd control within the emergency rooms as ambulatory patients, relatives, security/clinical personnel, and “unknown persons” mingled. It was obvious that the facility had challenges in handling such a large number of patients at such short notice.

Of the 50 victims who were brought into the emergency center, 45 were conscious on arrival. Amongst the 50 patients, there was a significant male preponderance (n = 49; 98%) with ages ranging from 4 to 88 years and a median age of 30 years (IQR = 37.5 years) [Table 1]. None of the patients received field triage or pre-hospital resuscitation. The majority (n = 45; 90%) of the patients had a Glasgow coma scale of 15. Injury patterns are shown in [Table 2] with five patients (10%) having multi-system involvement. Of the total number, 11 patients (22%) presented at the hospital with only minor lacerations and were discharged within 24 hours. The five multiply injured patients sustained penetrating wounds to the head, chest, abdomen, and the lower extremities [Figure 1]. Four of these victims died within 4 hours of being brought in, giving a mortality rate of 8%. More than half (n = 29; 58%) of the patients had penetrating injuries which were either deep open wounds or deep avulsion injuries of the lower limb, face, neck, and scrotum [Figure 2]. There was severe hemorrhage in twelve patients (24%) due to penetrating abdominal injuries (ten patients, 20%), open femoral fracture in one patient (2%), and one (2%) severe penetrating injury to the head and face. All required blood transfusion.
Figure 1: A typical severely injured patient with penetrating wounds to the face, head and chest

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Figure 2: A patient with penetrating injuries which were either deep open wounds or deep avulsion injuries of the lower limb, face, neck, and scrotum

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Table 1: Age and gender distribution of the MCI victims

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Table 2: Injury patterns of victims of the MCI

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The acute care interventions provided were aimed at preserving the lives of those injured. [Table 3] shows the details of interventions provided.
Table 3: Pattern of emergency care interventions provided patients

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  Discussion Top


The physical injuries caused by IEDs are often similar to those seen during military conflicts.[2],[3],[4] “Improvised” in this sense refers to the use of an explosive device outside of its intended purpose[6] and this can be worn as explosive jackets, hand-thrown as a grenade, or parked as “car bomb.”[6] The injuries caused by IED explosions have been properly documented in literature.[6],[8] IEDs contain high-order (HE) or low-order (LE) explosives or both. HE produce a supersonic shockwave, which characteristically ruptures air-filled organs e.g., tympanic membrane, abdominal viscus, and the lungs as a result of air-liquid interface shear.[8] The LE produce subsonic explosions with injuries primarily from metallic fragments and include pipe bombs, gunpowder, and petroleum-based bombs. They often lack the primary blast effect on tissues as HE.[6],[8] Injury severity is thus determined by the magnitude of the explosion, which is a measure of quantity and type of the explosive material and whether explosion occurred in the open or in an enclosed space.[8]

Civilian mass casualty events are becoming an increasingly important security issue all over the world.[9] Terrorism-related MCIs presently constitutes a realistic aspect of the daily existence in Northern Nigeria because of the ongoing insurgency which has claimed over 15,000 lives.[1] Organizational and clinical skills to manage large influx of acutely injured victims are key in MCIs. The principles of care in an MCI are quite different from everyday management of injured patients and involve mass triage and rapid decision making, often with the most experienced surgeon as the incident commander of a mass casualty team.[10]

Field or prehospital triage is an intricate part of any mass casualty response system. However, in settings like ours, where no such system exists, it is difficult to determine the overall benefits of hospital-based response.[11] When field triage is performed correctly, centers with maximum resources will receive the most severely injured patients.[12],[13]

The first consequence of a lack of systematic field triage was the bombardment of the acute care trauma unit of the center with an initial surge of 37 patients which exceeded our surge capacity of seven patients, thus overwhelming acute trauma care assets of the unit. An additional consequence of this were 11 (22%) over-triaged patients with simple lacerations (those deemed to have highly critical injuries, who however had very minimal injuries). Existing literature paradoxically favors higher over-triage rates and up to 50% is acceptable by most effective triage system in order to reduce the under-triaged rate to the barest minimum (less than 0.5%), i.e., the proportion of patients triaged as having non-critical injuries but who unavoidably had severe critical injuries.[12],[14] This approach was designed to inevitably save more lives using available trauma care assets. An over-triage rate of 22% in this study, therefore, may seem abnormally low. This proportion suggests that many more critically injured patients did not arrive at the study center until much later. Thus, lack of field triage may have lengthened the interval between injury and appropriate treatment in the severely injured. This arguably may be responsible for the mortality rate attributed to this MCI.[7],[12]

The overwhelming male predominance in this study is an indication of the existing sociocultural norms which tends to keep women indoors and disallows open worship for the female.[15] There were extremes of age (4–88 years) which suggested a predominantly communal lifestyle that allows people of different ages to mingle together particularly in places of worship.

The utilization of the anatomical guide (severity of visible external injuries) was a major component of the in-hospital triage in this study; thus, patients with obvious signs of bleeding, hemodynamic instability, penetrating head, chest, abdominal wounds, and the multiply injured were considered before others.[13],[16] The confusion and the large number of patients presenting at the same time made conventional triage impossible; hence, a simple, quick, and intuitive alternative was necessary in a center with no existing protocol.

Casualty generation (total number injured) and lethality (proportion that died) are the instruments of mass terrorism.[13] The immediate overall mortality from the MCI and all centers combined could not be determined because of a lack of information. However, the specific mortality rate in this population of patients was 8% which is considered low and comparable to the 7% in Leibovici's study,[17] another outdoor event. Had all the blasts in the Kano Central Mosque MCI occurred within the building, the mortality rate would likely have been greater because indoor blasts tend to magnify the destructive power of the blast wave and may collapse the building, burying more victims.[7],[12],[13],[18]

Crowd control and security were less than optimal at our facility during this event, as there was unrestricted access to the emergency unit. It is correct that institutional response to a MCI should involve the entire hospital; however, proper security for healthcare personnel, the injured, relatives, and others are major considerations in protocols designed for mass trauma response.[19] Agrawal et al.[20] and Shah et al.[11] in India and Pakistan, respectively, reported “follow-up” terrorist attacks within acute care rooms described as “second hit” phenomenon by Frykberg.[12] Even though Ozoilo et al.[14] justified inclusion of nonmedically trained personnel and medical/dental students in MCI response, the activities of these ought to be structured so as not to burden the existing security protocol and limit their engagement to what can be considered to be within the scope of knowledge and skills of a student.

Limitations

Our report is not without limitations. First the on-going healthcare workers' strike action in this analysis makes it difficult to assess the effectiveness of the “make-shift” response to this MCI event. Second, unavailability of data from other centers prevented the assessment of injuries and outcome of casualties from these centers for comparison. Our center is the farthest from the blast site and it is possible that more critically injured patients might have been transported to the two closer centers as a result of their proximity resulting in skewed data. Third, all injuries might not have been accounted for in view of the chaotic experience of sudden massive influx of injured patients. Finally, the lack of field and pre-hospital triage makes it more difficult to access the center's overall performance throughout this event.

In conclusion, we found that MCI response in Nigeria is still rudimentary compared to the standards in high-resource environments.[8],[9],[11],[21] Our findings demonstrate important areas for future improvement.

Since urban terrorism has become a reality in Northern Nigeria resulting in mass casualties, the following recommendations are worthy of consideration by the government and regulating agencies: a) Need for a comprehensive mass casualty response plan both nationally and within hospital settings, including training of standard emergency medical services personnel and provision of well-equipped ambulances for rapid site-evacuation of victims. It should include an organized and centralized medical dispatch system to facilitate inter-facility communication; b) Formation of hospital MCI multidisciplinary teams; c) Adoption of predefined MCI protocols that are suitable to the peculiarities of local environments; d) Periodic mock rehearsal of predefined mass casualty response plans; e) A need for increased government funding of hospitals focusing on MCI events.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Leibovici D, Gofrit ON, Stein M, Shapira SC, Noga Y, Heruti RJ, et al. Blast injuries: Bus versus open-air bombings--A comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma 1996;41:1030-5.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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