Analytical data of March 1993 blast victims--the KEM Hospital experience.SG Shenoy, PR Pai, S Dalvie, RD Bapat
Dept of General Surgery, Seth G.S. Medical College and KEM Hospital, Parel, Bombay, Maharashtra.
On 13th March 1993 consequent to a series of explosions in the city a large number of casualties were attended to at this hospital. A total of 248 patients were treated for various injuries which included 85 minor and 34 major operations. Seventy-nine patients were brought in "dead on arrival". There were 12 deaths after admission out of which 6 patients died after surgery. The cause of death was hemorrhagic shock in 5 patients, burns in 2, severe head injury in 2, and shock lung in 3 patients.
Keywords: Explosions, Human, India, Violence, Wounds and Injuries, etiology,mortality,pathology,surgery,
Management of mass casualties by general hospitals in India is on the rise due to the increasing incidence of violence. The use of sophisticated weapons and explosives by terrorists and other antisocial elements has led to injuries hitherto seen only in warfare or during military manoeuvres.
Bombay experienced a series of ten major bomb blasts on March 12, 1993. The explosive used was RDX detonated sequentially over widely scattered areas in the city. The blasts at the Stock Exchange building, Air India building and at Worli near the Passport Office accounted for most of the casualties. Our hospital received casualties from the Worli blast as well as those from a smaller blast at Dadar, and a few casualties from the Stock Exchange blast. A total of 248 casualties (excluding 79 brought in dead on arrival), were received at the KEM hospital within 5 hours from 14.30 hrs. to 19.30 hrs. The majority of casualties arrived in 2 waves of 20 minutes each with an interval of 30 minutes in between. The first wave brought about 200 victims from the Worli blast and the second 48 victims from the Dadar blast. Such a large number in so short a time tended to overwhelm medical facilities at the hospital. Timely action taken helped in mitigating this problem and taught some valuable lessons in disaster management; these are discussed here.
Casualties saturated the usual receiving area of the hospital in a few minutes and hence two more contiguous supplementary receiving areas were opened manned by all medical personnel available in the hospital at that time. Surgical Units were regrouped as shown in [Table - 1]. Casualties were triaged into serious, expectant and minimal categories. Serious patients requiring resuscitation were treated in the resuscitation room prior to being transferred to other areas for definitive treatment. Due to the rapid influx of patients the Registration Department could not allot registration numbers. Therefore temporary registration numbers were assigned to facilitate patient identification. Blood was similarly sent for grouping and cross matching with these arbitrary codes. Patients requiring emergency major surgery were accompanied by interns or medical students who acted as communication relays and ensured that blood reached the operation theatre for transfusion in time.
Patients requiring observation were shifted to two other wards situated nearby. These were monitored by a surgical unit.
Patients with multiple minor wounds were treated exclusively by one surgical unit in two operation theatres. Major operations were carried out by three surgical units assisted by super speciality units as and when required [Table - 1]. A detailed record of injuries as well as operative procedures performed was maintained.
Post-operatively patients were transferred to either the surgical intensive care unit or to post-operative wards depending on the clinical state of the patient.
Out of the 248 casualties received, 86 required admission and treatment. There were a total of 85 minor. Number surgeries performed (local explorations for suturing of incised wounds or contused lacerated wounds or for removal of superficial shrapnel. Four patients from this group required further management (two required only observation, one a splenectomy and one required femoral artery repair). There were 34 major surgeries performed [Table - 2].
These included 7 major abdominal surgeries, 1 craniectomy, 4 vascular repairs, 1 nerve repair, 2 neck explorations and 7 orthopaedic surgeries and 12 local explorations for shrapnel injuries. 1 patient required multi-speciality approach for ophthalmic injury (requiring evisceration of the eye) and abdominal injuries (requiring resection and anastomosis of multiple ileal and colonic tears).
The casualties found dead on arrival were 79 in number. There were a total of 12 deaths after admission: 6 post-operative and 6 unoperated or prior to operation. The injuries sustained in these cases are listed in [Table - 3]. Most of the deaths (11 of 12) occurred within the first 24 to 48 hours.
No post-mortem examination was performed in view of the extreme load. The causes of death ascribed clinically are listed in [Table - 4].
The cause of injury following detonation of an explosive device is multifactoral,. Primary injury is caused by the blast wave alone as a result of the interaction between the human body and the set up stress, shock and shear waves. Secondary injuries are caused by the bomb casing and other secondary missiles, which result in blunt or penetrating injuries. Tertiary injuries are caused by the blast wind, which results in traumatic amputations or head injuries. There may also be flash burns due to the heat of the explosion or crush injuries caused by falling masonry.
The predominant factor and the severity of injury depends on the distance from the detonation and the blast loading which determines the overpressure the victim was exposed to,. In the first zone nearest the blast where the overpressure may be in excess of 550 kPa there is disruption of the body with no survivors. At the limit of this zone death is not due to disruption but due to severe primary lung injury. In the second zone over pressures are between 350 to 550 kPa and there are a few survivors with injuries mainly due to secondary missiles and primary lung damage. In the outermost zone the over pressure is less than 350 kPa and there are many survivors and few cases of primary lung damage. Most of the deaths in this group are due to head injuries. In almost all these patients there is also traumatic rupture of the tympanic membrane. Consequently all patients with evidence of tympanic membrane rupture must be closely observed for signs of lung damage, which may manifest after 24 hours.
Injuries sustained also depend on whether the victim was indoors as the blast wave tends to get reinforced by reflection from walls. This effect is seen typically at corners of a room.
Air filled organs like the ear, lungs and gas filled bowel are maximally damaged by the blast wave. The shear wave tends to damage solid viscera causing laceration and tearing of the mesentery and vascular pedicles. The blast wind causes disruption of the exposed tissues and leads to traumatic amputations. It has been reported that casualties sustaining proximal traumatic amputations rarely survive. However, in our series, one of the two cases of traumatic amputations survived in spite of lung contusion. A high index of suspicion of lung trauma is vital for early diagnosis, treatment and better prognosis as the signs of lung damage and subsequent shock lung syndrome typically manifest after 24 hours. In this disaster there were 3 deaths due to shock lung syndrome, which manifested after 24 hours.
The most important aspect in managing this disaster was proper triage as it allows optimal utilisation of scarce hospital resources.
The problems encountered in the management of this catastrophe included those relating to mobilisation and deployment of personne1, registration of casualties, mobilisation of space for triage, resuscitation, observation and treatment and problems in public relations.
The sudden influx of casualties tended to overwhelm medical facilities. This difficulty was met by systematic utilisation of all six general surgical units, super speciality units, medical and allied units as well as interns and medical students [Table - 1].
The unit on emergency duty for that day manned the triage areas and the resuscitation ward. They were assisted by an ample number of interns and medical students in addition to the surgical unit sharing the ward (corresponding unit), which also manned the observation and the postoperative wards. Medical students and interns in addition to helping in resuscitation, were used for registering patients with code names and indoor numbers and sending blood for grouping and cross matching. Each patient requiring major surgery was accompanied by an intern who monitored the patient in transit and also acted as a communication relay between the triage or resuscitating personnel and the operating personnel. They were also used for mobilising other speciality personnel in case of multi system injuries. The post-emergency unit and the remaining 2 general surgical units were deployed in the available operation theatres of which 2 theatres with 4 operating tables were reserved only for treating minor injuries and the rest reserved for major abdominal surgeries. Patients with special system injuries like head, chest or vascular, orthopaedic were directly sent to the respective theatres after resuscitation,
Other problems faced included keeping records in the triage and resuscitation areas. The solution probably lies in maintaining ready made proformas and a uniform system of wound classification like the Red Cross E.X.C.F.V.M. scoring system. Similarly triaging patients into expectant, serious (urgent, immediate or delayed) or minimal categories also helps in streamlining management,,.
The need for emergency medical attention precluded proper registration formalities. There was also an added difficulty of absence of name in case of unconscious patients as no relatives were present. This difficulty was met by preparing stickers bearing code names and numbers, which were taped to the patientís chest or forehead. Duplication was prevented by placing a single staff nurse in charge of this duty. A more efficient method would be to store a large number of plastic or metal bracelets with temporary registration numbers.
The present receiving and resuscitation area has a capacity of only ten beds. This proved to be grossly inadequate and was used only for resuscitation of serious patients triaged in contiguous supplementary receiving areas specially opened for this purpose.
Supplementary operation theatres were obtained by utilising routine general surgical operation theatres as well as those from other specialities.
Public relations as well as preparing casualty lists were another major difficulty as a large number of relatives flocked the hospital. A news bulletin renewed every hour was announced over a Public Address system and was also displayed in a prominent place.
Separate holding areas were arranged for identification, and documentation of the large number of bodies brought dead on arrival.
This experience once again demonstrated the need for an improved integrated disaster protocol for the institution.
We thank the Dean, Seth GS Medical College & King Edward Memorial Hospital for allowing us to publish this data. We also appreciate the efforts of all surgical and allied units, medical and non-medical staff without whose help it would have been well nigh impossible to have treated so many patients during the crisis.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]