Analytical data of January 1993 communal riot victims--the KEM Hospital experience.SS Dalvie, PR Pai, SG Shenoy, RD Bapat
Dept of General Surgery, Seth GS Medical College and KEM Hospital, Parel, Bombay, Maharashtra.
Bombay experienced a violent outbreak of communal rioting in January 1993. Four hundred and thirteen casualties were treated in the KEM hospital from January 7 to January 15, of which 194 required admission and further management. Twenty-seven were brought dead on arrival. The large influx of casualties sustained over a period of 9 days tended to overwhelm the medical facilities. The data of the admitted patients are analyzed to identify the frequency of admissions, cause and nature of injuries sustained, management and prognosis of casualties in such a catastrophe. An attempt is also made to identify the problems faced during such a crisis and a few suggestions made for their solution.
Keywords: Adult, Female, Human, India, Male, Middle Age, Riots, Wounds and Injuries, etiology,pathology,surgery,
Management of mass casualties by General Hospitals in India is on the rise in view of the increasing organized violence and the deteriorating law and order situation with use of sophisticated arms and ammunition by terrorists and antisocial elements. This has resulted in a higher exposure to high velocity bullet injuries and blast wounds hitherto seen only during warfare and military maneuvers.
Bombay has experienced two incidents of widespread violence in the months of December 1992 and January 1993. The resulting mass casualties tended to overwhelm the medical facilities geared for the usual civilian medical emergencies and injuries.
In the January 1993 riots, 413 casualties were treated in the King Edward Memorial Hospital and 27 were brought dead on arrival. One hundred and ninety-four casualties required admission and further management, of which 35 died after admission. The data of the admitted patients were analysed in detail to identify the population at risk, the frequency of admissions, the cause and nature of injuries sustained, management and prognosis of victims in such a catastrophe. The study is aimed at defining the problems in such a crisis and improving the protocols for disaster management.
Casualties resulting from arson, violence and firing by law and order agencies were received in the casualty and other triage areas, where they were rapidly assessed and triaged into 3 categories viz. expectant (who were likely to succumb to their injuries in spite of treatment), serious (who were unstable and may require resuscitation with immediate, urgent or delayed surgical intervention or observation) and minimal (ambulatory casualties with superficial wounds not requiring admission).
Casualties in the first two groups were shifted to the resuscitation ward where they were stabilized, assessed in detail and shifted to the respective operation theatres, depending on the main injuries. Prior to shifting, the patients were given temporary code names and registration numbers when identification was not possible. Blood was similarly sent for grouping and cross-matching. These patients were accompanied by medical students and interns who monitored them in transit, acted as communication relays between resuscitating and operating personnel, ensured that blood was made available in time for transfusion and mobilized speciality surgical personnel when multi-system injuries were encountered. Patients requiring minor surgery were referred to operation theatres reserved for this purpose. Patients requiring only observation were shifted to observation wards. A detailed record of the injuries sustained and the operative procedures carried out was maintained.
They were then shifted to post-operative or intensive care wards. The patients were followed up till their discharge (or death) and were classified as having completely recovered or as having some residual deficit.
The authors gathered epidemiological, medicolegal and clinical data of these patients and analysed them with respect to frequency, distribution, nature of injury, classification, management and prognosis.
Over period of 9 days, 440 casualties were brought to the King Edward Memorial hospital, of which 219 patients were treated as outpatients, 194 were admitted and 27 were found dead on arrival. Of the admitted patients, 132(68%) were Hindus, 58(29.3%) were Muslims, and 1 was a Christian and 3 were unknown. There were 181(93.3%) males and 13 females. The age distribution of the patients is given in [Figure:1].
[Figure:2] displays the pattern of admissions (admissions/day), showing a steep increase in the number of patients till January 10 (day 4), followed by a decline. [Figure:3] shows the pattern of admissions of patients coming with stab injuries as compared to bullet injuries.
Analysis from the medicolegal point of view revealed mode of injury sustained by the patients as shown in [Table - 1]. The largest group of injuries were caused by bullets (98), with blunt (47) and stab (44) injuries following. Twelve patients came with burns. Seventy-two of the 98 bullet injuries were sustained above the waist. Of the stab injuries 18 were caused by choppers and 13 were caused by knives, the rest being due to swords, guptis and unknown objects. Medicolegal classification of the injuries showed 52 to be fatal, 88 to be grievous and 54 to be minor.
On admission the general condition (vital parameters) of the patients showed that 133(68.5%) patients were stable, 32(16.5%) were in mild to moderate shock (pulse between 100 and 120 per min, BP between 80 and 100mm/Hg), 15(7.7%) were critical (pulse greater than 120 per min, BP less than 80mm/Hg) and 14(7.2%) were gasping (pulse not palpable, BP not recordable with abnormal breathing pattern).
As regards site of injury, 93 patients had limb trauma, 61 had head injuries, 22 had chest trauma, 50 had abdominal trauma and 43 patients had injuries involving more than one site, not considering the 12 patients with burns.
Among the patients with head injuries, only 8(13.1%) patients came with altered consciousness. Ten (l 6.4%) patients were unstable on admission and 8 eventually died. Major surgical intervention was eventually required in only 2 patients. Majority of the patients had wounds, which required suturing or were kept for observation only.
Of the patients with chest trauma, 13(59%) had a hemothorax. Six patients were unstable and 1 died after admission. Thirty-eight patients suffered from fractures, of which 31 were compound. Ten patients each had nerve injury and vascular injury.
Eighteen (36%) of the patients with abdominal trauma were unstable on admission. Thirty-six of the 50 patients had injury by either a sharp instrument or a bullet, the remaining being blunt. Twenty of the 36 injuries extended beyond the peritoneum. The various internal injuries sustained are shown in [Figure:4]. Eight patients with abdominal trauma died after admission.
Surgeries performed included 62 major and 99 minor operations (wound suturing, wound exploration and debridement, intercostal drain insertion etc.) were performed. Forty-two exploratory laparotomies were performed of which 23 had no positive findings. Operations performed included treatment of 22 bowel injuries (suturing of tears, resection anastomosis, exteriorization etc.) and 11 solid organ injuries. The various intra-abdominal procedures performed are shown in [Table - 2].
Seven fractures required external fixation and 5 required internal fixation. Seven vascular repairs and 1 nerve reconstruction were carried out, one patient required an amputation.
Sixty-one patients were treated with "higher" antibiotics while 133 received antibiotics available on schedule (Ampicillin, Cloxacillin, Gentamicin etc.).
Fifty-two patients stayed for less than 2 days, 73 patients stayed between 2 to 7 days, 39 patients stayed between 8 to 15 days and 30 patients stayed for more than 30 days. The average stay of the riot patient was 10.34 days. Complete recovery was found in 116 (59.8%) patients, 41 (21.2%) had some residual deficit (ranging from paralysis, palsies, deformities, disfigurement and limb-loss.) and 35 (18%) of the admitted patients died. Twenty-nine of the dead had been unstable on admission and 26 patients died within 24 hrs of admission. Eleven of the 12 patients with burns, died after admission. These are in addition to the 27 patients who were dead on arrival and are not considered in this study.
This series shows a large predominance of males, with female patients being less than 7%. A sizable majority of the patients belonged to the majority community found in the area of drainage of the hospital. Fifty-one per cent of the patients belonged to age group 21 - 30 years, and almost all patients were from the active age group (16 - 50 yrs.). This is the population, which is out on the road during a riot. Prognostically this is an advantage, as the younger patients will have better chances of survival.
The pattern of daily admissions shows a sharp increase in the number of admissions after the commencement of the riot. This shows the tendency of some communal riots to spread and multiply, indicating that at the outset of a riot, the medical services should be prepared for the worst. Admissions of bullet injuries showed a sudden peak on day 4, indicating the onset of the control measures, following which there was a sudden drop. Admissions due to stab injuries was maximum just before the peak, with a gradual decrease indicating that the control measures were effective against the rioting mob, but sporadic incidences did continue to occur. Bullet injuries were seen in the largest number of patients. It indicates that riot control brought a larger number of casualties to our hospital than riot victims per se. Furthermore, a large majority of these injuries were above the waist, in contradiction to the injuries usually expected arising from riot control.
Only 19 of the 194 patients arriving in the casualty/triage area were critical or gasping, while the rest were essentially stable. Hence triaging prevents overcrowding in the resuscitation ward permitting optimal utilization of medical facilities.
Injuries were present at many sites, of special note being the 42 patients with multi-system trauma, requiring close coordination between the various specialities like general surgery, orthopedics, plastic surgery, cardiovascular and thoracic surgery, urology and neurosurgery.
Head injuries were characterized by a large number of patients requiring only observation and/or wound suturing. Notably only 2 required neurosurgical intervention. Thirty-six of the 50 patients having abdominal trauma had injury with bullet or sharp object Twenty of these were found to extend beyond the peritoneum, thus requiring an urgent exploratory laparotomy to rule out intra-peritoneal damage. However 22 of the remaining 30 patients who were kept under observation had to be explored eventually. Twenty-three of the 42 laparotomies performed did not detect any internal injuries. The surgical dictum of an exploratory laparotomy whenever a penetrating injury extends beyond the peritoneum should be strictly followed even if it turns out to be negative.
Management of limb injuries in patients with major systemic trauma usually takes second place and temporary stabilization with splints and slabs was required. Definitive surgery was required in only 12 of the 38 fractures, the rest being managed conservatively by plaster - casts and slabs. The high incidence of compound fractures necessitated early wound exploration and debridement.
The number of major and minor surgeries, the use of expensive antibiotics and the hospital-stay of the patients are measures of the economic stresses on the hospital at the time of a riot.
A disaster such as a riot brings patients with trauma essentially similar to that in normal times. The difference lies in the distribution of patients, their large numbers and the length of time over which they come and the higher incidence of high-velocity bullet injuries. Readiness for such an event depends on the knowledge of the types of injuries and patients expected, principle of triage, mobilization and coordination of adequate trained manpower, preparedness for resuscitative and investigative facilities, efficiency of blood-bank services and existence of an effective disaster management protocol with built in contingency measures. Prognosis and mortality in such a calamity is directly proportionate to the effective drill that the hospital is used to, taking into account its past experience.
The problems faced during this crisis included those relating to mobilization, deployment, sustenance and security of personnel (medical and non-medical), maintenance of adequate stock of resuscitative, operating and therapeutic medical equipment and blood-transfusion, registration of patients, mobilization of space for triage, resuscitation, observation and treatment and problems in public relations.
On account of wide-spread violence and total disintegration of law-and-order the hospital was isolated from the outside. Non-residential medical staff had to be brought by, ambulance. They were deployed on a rotation basis in the triage, resuscitation, operating and treatment areas. Optimal utilization of medical facilities was ensured by triaging casualties. Non-medical staff such as, sweepers and ward boys were requested to continue working beyond duty hours, as replacement staff could not make it to the hospital. As a result of the closure of eating- places, the personnel had to rely on the hospital kitchen, mess and canteen for their meals. These too were taxed, as adequate supplies were not in stock. Security of personnel was also a problem as several acts of violence were carried out within the hospital premises. Deployment of armed central reserve police force ensured security later on.
The high influx of casualties created a massive load on existing medical equipment and drugs required for resuscitation, treatment and operations. These could be mobilized by opening the stores situated within the campus. Requirement of blood for transfusion was effectively taken care of by the existing stocks and blood donation by relatives and well-wishers ensured replacement of depleted stocks.
The need for emergency medical attention for a large number of casualties precluded proper registration formalities. In addition, there was added difficulty due to the absence of names in unconscious casualties without relatives. This problem was handled 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 existing receiving and resuscitation area was inadequate with its capacity of 10 beds as the casualties arrived in batches related to acts of arson or firing by law and order agencies. Hence this area was used only for the resuscitation of critical patients triaged in contiguous receiving areas specially opened for this purpose. Supplementary operating theatres were obtained by opening all the routine theatres as well as those from other specialities.
Preparing casualty lists and public relations were other problems, as a large number of relatives flocked to the hospital. Regularly updated news-bulletins were displayed in prominent places. Special areas were created for placing the bodies brought dead on arrival or dying after admission for the purpose of identification. Medicolegal post-mortems were a problem due to the number of bodies and as the Coroners-court was situated far away. Hence a coroner was called to the hospital to carry out post-mortems there itself.
This experience demonstrates the needs for an improved, integrated disaster protocol with streamlined contingency measures to tackle the various problems created by such catastrophes.
[Table - 1], [Table - 2]