Original Article
European Journal of Trauma
Triage in a Bomb Disaster with 166 Casualties Markus Torkki1, Virve Koljonen2, Kirsi Sillanpää1, Erkki Tukiainen2, Sari Pyörälä3, Esko Kemppainen4, Juha Kalske5, Eero Arajärvi6, Ulla Keränen7, Eero Hirvensalo1
Abstract Background: We describe the surgical response of the Helsinki University Hospitals to a bomb disaster with 166 casualties. According to the Helsinki Area Disaster Plan, severely injured patients were transported to several hospitals with emergency facilities to avoid overtriage. Methods: The patient data were gathered from hospitals, health centers and other doctor visit/ appointments records. Injury Severity Scores (ISS), critical mortality rate and death/wounded ratio were calculated. Results: Of the 166 injured patients, 5 died immediately at the bombing site. Sixty-six patients were transported to the six affiliated hospitals. The mean ISS score for survivors was 12. Seventeen percent of the acute survivors were critically injured (ISS>15). The critical mortality rate was 8%. There were no later deaths; the dead/wounded ratio was 4.4. Operative treatment was performed for 38% of the patients treated in surgical emergency departments. Conclusion: The bombing attack in Myyrmanni shopping center led to 166 casualties, of whom 66 patients were received at six affiliated hospitals in Helsinki and Uusimaa Area. The critical mortality rate was low. A local disaster plan was implemented. The surgical response was rapid and well coordinated. In a mass casualty disaster not all disaster victims need to go to a trauma center.
Key Words Bomb explosion · Terrorism · Mass casualties · Surgical response Eur J Trauma 2006;32:374–80 DOI 10.1007/s00068-006-6039-8
Introduction Civilian mass casualty events are becoming an increasing security concern all over the world [1, 2]. Rignault and Deligny have defined “mass casualty bombings” as catastrophes claiming 30 or more casualties [3]. Regional trauma systems are beneficial to ensure effective treatment of trauma patients in mass casualties. Although trauma centers assume the leadership role, in a truly inclusive system, all healthcare providers (prehospital providers, community hospitals and trauma centers) have a defined role in providing care to patients with trauma. As a result, patients receive treatment at the appropriate institution, resources are allocated appropriately, and the clinical outcome is optimized. An effective trauma system requires a strong administrative infrastructure and an effective communication system [4]. Different bomb types result in unique patterns of injury [5]. Most victims sustain minor injuries. The injuries affect predominantly the head, neck and
Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland, 2 Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland, 3 Department of Pediatric Surgery, Hospital for Children and Adolescents, Helsinki University Hospital, Helsinki, Finland, 4 Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland, 5 Department of Surgery, Jorvi Hospital, Espoo, Finland, 6 Department of Surgery, Peijas Hospital, Vantaa, Finland, 7 Department of Surgery, Hyvinkää Hospital, Hyvinkää, Finland. 1
Received: April 3, 2005; revision accepted: September 4, 2005.
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extremities. Injuries to the chest and abdomen are less common but carry a higher mortality, as is the case for head injuries. The pressure wave generated by an explosion results in a primary blast injury which is a form of a barotrauma. Patients with primary blast injuries are not seen in hospitals, because these injuries usually result in immediate death [6, 7]. The injury is caused by pressure gradients between internal organs and the outer surface of the body at the moment of pressure wave impact. Organs that contain gas, i.e., the lungs, gastrointestinal tract and ear, are the most vulnerable to injury [8]. The proximity to the detonating device is obviously more important than the size of the bomb in primary blast injuries. Victims at distances beyond 6 m from the average sized detonating device will probably not experience substantial blast-induced injuries [2]. Confined space explosions result in more severe blast injuries than open-air explosions [9]. Bomb explosion victims sustain also other injuries. These include penetrating injuries from flying debris (secondary blast injuries) and blunt trauma injuries (tertiary blast injuries) from propulsion of the body against stationary objects and structures [10, 11]. Injuries to soft tissues and bony structures may also result from collapsing buildings and fire outbreaks which cause thermal injuries [11, 12]. If the victim is close to the blast, traumatic amputation of extremities may follow [2]. In today’s world preparing a bomb does not require any special skills. The most popular bomb type is the pipe bomb. It is simple and easy to make and details of bomb construction are readily available from the Internet [11, 13]. This type of bomb is usually filled with metallic additives, small and sharp objects, to cause maximum amount of damage to surrounding humans when the bomb explodes [13, 14]. Myyrmanni Explosion The Myyrmanni shopping center in the Helsinki metropolitan area was hit by an explosion on a Friday evening, 11 October 2002, at 7.36 p.m. The shopping center was crowded with families accompanied by children. A self-made explosive detonated in the central square of the shopping center and caused a massive explosion. As a result, the person who prepared and brought the explosive to the shopping center and four other people were killed immediately. Two more people died at hospitals. Nearly 200 people suffered injuries of various degrees, and 159 people sought some kind of medical assistance.
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The police received the first alarm of the explosion, immediately after the blast, from a customer in the Myyrmanni shopping center through cellular phone. Initially, a gas explosion was suspected. The terrified caller reported several injured and dead. The roof structures were told to have collapsed partly. The first rescue team on site was Vantaa fire department’s team at 7.40 p.m. A helicopterambulance team lead by a physician/anesthesiologist arrived at 7.45 p.m. to the bombing site. The helicopter physician/anesthesiologist took the medical leadership at the bombing site. The first patient was transported from ground zero to the Hospital for children and adolescents (distance of 10 km from the bombing site) at 7.53 p.m., 17 min after the explosion. The last injured patient was evacuated 1 h after the explosion, at 8.35 p.m. We report the experience of the Myyrmanni mass casualty bombing in the Helsinki area and discuss the rescue and treatment response in the surgical departments of the hospitals involved. Patients, Materials and Methods The study included the patients treated at the surgical departments of the hospitals of the Helsinki University from 11 October 2002 and the following week. The patients were primarily treated in the emergency departments of six hospitals (Figure 1). The pattern of injuries and primary operations were recorded from the data on the patient charts. An Injury Severity Score (ISS) for every victim was calculated by two of the authors (K.S., M.T.). Patients with ISS > 15 were considered severely injured. Critical mortality was defined as the number of deaths among the patients triaged to survive (i.e., excluding expectants or deaths on arrival), correlated to the patients with ISS > 15 [15]. Two weeks after the disaster, each primary healthcare center in the Helsinki and Uusimaa area was asked to report every patient who had sustained any bomb-related injury on 11 October 2002. In addition, police investigation records were reviewed to identify the patients who contacted other medical services. These data were then combined with the hospital records. Patients who had not been referred to hospitals were considered to have had only minor injuries. The Finnish National Bureau of Investigation interviewed 115 people injured at the explosion. The location of each interviewed person at the moment of the explosion was reconstructed and marked in the floor plan. The severity of the injuries was marked into the plan as follows: black = dead; red = treated in
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a hospital, ISS > 15; yellow = treated in a hospital, ISS 15 or less; green = injured but not treated in a hospital (Figure 2).
Figure 1. Location of the six hospitals where the most severely injured patients were primarily treated.
Results The bomb in this explosion was a selfmade, pipe-type bomb containing metal pellets normally used in shotguns. The explosive compounds were also self-made and consisted of a mixture of nitromethane and ammonium nitrate. This mixture was packed in a 1.5 l plastic bottle which was covered with thousands of 4.5 mm steel and lead pellets. The ignition system and detonator were self-made, as well. The detonator was battery-operated and investigations revealed that some kind of a timer was also used. The point of explosion was on top of a metallic litterbin. Analysis of the explosion stains showed that the initial velocity of metal pellets was 1,000 m/s, and they spread around 360º. The pieces of damaged litterbin were shattered, and fragments of the structure increased the amount of shrapnel and the devastation. The shrapnel and pellet stains covered an area of 100 m in diameter.
Figure 2. Location of victims at the moment of explosion. The bomb exploded at point G. Black = dead; Red = treated in a hospital, ISS>15; Yellow = treated in a hospital, ISS 15 or less; Green = not treated in a hospital.
Hospital Responses The Töölö hospital is a tertiary hospital, the main trauma unit (level I equivalent) of the Helsinki University Hospital. As the leading trauma center in southern Finland, it serves 1.7 million inhabitants, which is more than one-fourth of the population of Finland. According to the preliminary national and Helsinki and Uusimaa regional disaster plan, it coordinates and directs other hospitals in its region. The plan is grounded on the inclusive trauma care system principle. In disasters, the chief trauma surgeon of the Töölö hospital is the leading medical officer, coordinating the operation of all emergency hospitals in the area. Each hospital has during catastrophes its own surgeon in charge according to the hospital disaster plan.
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The Töölö Hospital was informed of the explosion from the regional alarm center at 7.46 p.m., 10 min after the explosion. At 7.55 p.m. the senior orthopedic surgeon on-call (M.T.) gave a level-1-alarm, which is intended for a low-patient-volume scenario (less than 100 casualties). The leading medical officer of the Töölö hospital (E.H.) was alarmed at 8.00 p.m., he arrived at the Töölö Hospital at 8.30 p.m., and after this he was in command of the medical activities of all six hospitals (Figure 1). At 7.57 p.m. the staff in the hospital were informed not to leave the hospital. Immediately after this, the emergency ward was cleared of patients. Extra staff was alarmed according to the disaster plan at 8.05 p.m. At 8.30 p.m. the emergency ward was prepared to receive seven critically injured patients. At the same time, the first two victims of the bombing accident arrived at the hospital. Twenty-nine surgeons and 108 nursing staff members had arrived at the hospital by 9.00 p.m. The other hospitals were alarmed by the Töölö hospital. The Meilahti, Jorvi and Peijas hospitals received the alarm calls between 8.05 and 8.10 p.m., and nurses and physicians were called as determined in the respective disaster plans. The Hyvinkää hospital was initially not alarmed until a call from the ambulance staff. The Hospital for children and adolescents did not receive an alarm until the first patients arrived. Communication According to the disaster plan, the leading physician at the bombing site informs the Töölö hospital through phone and reports the number of casualties and the type of disaster. In this case, this did not take place because of technical problems. The mobile phone network was too busy as concerned citizens tried to contact their relatives and friends. The ambulance-helicopter anesthesiologist attempted to call the Töölö hospital on several occasions but did not succeed. All information to the Töölö hospital was mediated by the Helsinki alarm center. The data they transferred could not be considered accurate. The Töölö hospital was first informed that gas bottles probably caused the explosion. Further, the number of casualties was clearly underestimated. According to the first call it was claimed that there were only “one seriously injured child and perhaps ten more injured adults”. However at 8.10 p.m. the hospital staff saw on TV that there were at least five casualties, and it was obvious that the amount of severely injured patients would increase substantially. The hospitals were alarmed and the communication between them was established through telephones. All information about the victims was collected in Töölö and submitted to the leading medical officer (E.H.). The
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hospitals transmitted patient information to the Töölö hospital by facsimiles or by telephone calls. There were no major problems in communication between the hospitals. The chief nurse (K.S.) established a patient information center in the Töölö outpatient clinic at 8.45 p.m. Every patient’s identity was ascertained by 4.10 a.m. on 12 October 2002 (8 h after the explosion), and concerned family members could be appropriately guided to the right hospitals. This telephone help was available until 8.00 a.m. 15 October 2002. Altogether 400 calls were answered. Injuries and Treatment A total of 166 persons were injured in the explosion. The immediate death rate was 3% (5/166). Sixty-six patients needed hospital treatment. The data of these patients is presented in Table 1. The mean age of the patients was 28 years (range 2–71). One-fourth of the patients were under 16 years of age. Twenty-five of 66 patients (38%) underwent altogether 40 surgical operations during the first week after the bombing (Table 2). Many surgical subspecialties were needed to treat these patients: gastroenterologists, thoracic surgeons, vascular surgeons, orthopedic surgeons, plastic surgeons, pediatric surgeons and ophthalmologists. Most of the injuries concerned the extremities and trunk. The metal additives in the bomb resulted in multiple soft tissue wounds, mainly to the lower extremities. These patients typically underwent revisions and fasciotomies to the lower extremities. In addition, minor surgical operations, like wound revisions and suturations under local anesthesia, were performed for 9 (out of 66; 14%) patients. Forty-one (35%) of 115 victims interviewed by the Ministry of Interior reported hearing disabilities. Twenty-nine patients were treated for ear trauma in the Department of otorhinolaryngology of Helsinki University Hospital. Of them, 65.5% had tinnitus as the initial symptom, 55.2% hearing loss, 41.4% pain in ears and 27.5% sound distortions [16]. All eight patients who suffered a rupture of the tympanic membrane had been at a distance of less than 10 m from the point of explosion [16].
Table 1. Data of the 66 patients requiring hospital treatment. Values are numbers and percentages of all 66 patients treated in hospitals.
Female gender Age under 16 years ISS > 15 Surgery
N
%
33 17 13 25
50 26 20 38
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Table 2. Operations performed during the first week after the disaster. One of the operated patients died postoperatively. Values are expressed as number of operations. Note that some patients underwent multiple operations; the total number of operations (40) exceeds the number of operated patients (25). Operation type
N
Wound revision (fasciotomies included) = 16 Head and neck
4
Upper extremity
2
Lower extremity
10
The first two patients treated in Meilahti hospital needed emergency surgical treatment. One of them had pericardial tamponade, the other had an intra-abdominal bleeding due to a ruptured iliac artery. Immediate surgery saved their lives. However, one patient who was initially triaged to the regional Peijas hospital was diagnosed with intra-abdominal bleeding and an urgent laparotomy was performed. During laparotomy, the patient became hypovolemic, and immediate thoracotomy was performed. The axillar artery had ruptured with subsequent hemothorax of 2 l.
Laparotomy (main procedure) = 10 Suturation/reconstruction of major vessels
3
Bowel resection
4
Bowel suturation
1
Splenectomy
1
Explorative laparotomy
1
Fracture fixation = 7 External fixation
4
Internal fixation
3
Thoracotomy (main procedure) = 3 Heart suturation
1
Axillar artery suturation
1
Lung suturation
1
Vascular reconstruction of extremities = 3 Popliteal bypass
1
Forearm revascularisation
1
A. et V. poplitea reconstruction
1
Suturation of trachea and esophagus = 1 Total number of operations
40
Primary Triage The triage flow chart is presented in Figure 3. The dead/ wounded ratio during the first 24 h was 1:23 (4.4%). Of the 161 primary survivors, 55 were initially triaged as moderately to severely injured and transferred to surgical emergency departments: to Töölö hospital 5 patients, to Meilahti hospital 4, to Hospital for children and adolescents 9, to Jorvi hospital 16, to Peijas hospital 15 and to Hyvinkää hospital 6 patients (Figure 4). The triage in the field was done on the basis of four categories: T1 (unstable), T2 (need hospital care), T3 (outpatient medical care) and T4 (dead or T1 hold). Of the106 patients who sought medical care in health centers or other medical services, 11 were referred to surgical departments as emergencies. Thus, the total number of patients treated in the surgical emergency departments of the six hospitals was 66. Of the 66 patients, 13 (20%) were critically injured (ISS > 15, Table 1). Of these 13 patients, 2 died because of lethal brain and thoracic injuries during the following 24 h. One of them died just after admission to the
Figure 3. Triage flow chart of Myyrmanni bombing incident; data gathered from regional hospitals, health centers and police interrogations.
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Figure 4. Primary triage of the severely injured patients. Red columns are critically injured patients (ISS>15), yellow columns non-critically injured patients. a) Hospital with level A trauma facilities, b) regional hospital.
Hospital for children and adolescents and another died in the Töölö hospital. Discussion Mass destructions by bombing and shooting are by far the most common form of terrorist violence [15]. Since the end of World War II there have been only a few mass casualty bombings in Finland. The severest was the explosion of an ammunition factory in central Finland (Lapua) in 1976, which resulted in 40 casualties [17]. In this paper, we present a bombing case with 166 casualties, which is the severest disaster in Finland after World War II. Although this was not a terrorist act as such, it fulfills the criteria of randomness and its profound impact on civilian population. A motive for the explosion was not found despite a thorough investigation made by police officials. The disaster took place in a shopping center on a Friday evening, a popular time for young families to make weekend shopping. Innocent civilians, including children, were injured, and seven died. Patients suffered primary, secondary and tertiary blast injuries. Most patients or 100 out of 166 (60%) sustained minor, non-life-threatening injuries, which is a typical finding in bombing disasters [10, 15]. Sixty-six out of 166 (40%) patients were treated in the surgical emergency departments of six hospitals in the vicinity of the shopping center. Triage in the hospitals was ATLS based. The injuries were predominately penetrating injuries from flying debris (secondary blast injuries) to the lower extremities. The main finding in this study is that triage is more effective if all regional trauma care capacity can be utilized for disaster victims. The importance of triage for the proper management of mass casualties from terrorist bombings has been emphasized [18]. Rapid and accurate triage significantly minimizes mortality among survivors [18]. In this case, there were enough rescue staff and vehicles available at the scene and the patients
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were evacuated quickly to the hospitals. A helicopterambulance anesthesiologist performed triage at the bombing site successfully. The inclusive trauma care system ensured rapid care for all the patients. The triage was done according to the disaster plan, which requires also the regional hospitals to take one to two severely injured patients. The most severely injured patients were transported mainly to the three hospitals that treat multitraumatized patients in their everyday practice, namely Töölö, Meilahti and the Hospital for children and adolescents. Because of some undertriage, there was free capacity in two of the hospitals (Töölö and Meilahti), and more patients could have been treated there. An overtriage rate of 50% is accepted in trauma centers under normal circumstances as a necessary price to pay with the intention of neglecting potentially lifethreatening injuries [15]. However, in a mass casualty disaster not all dis aster victims need to go to a trauma center. Overtriage could be as life-threatening as undertriage, since medical facilities are inundated in the face of large numbers of less injured patients at the same time. Such overtriage may prevent the appropriate detection of a small minority of patients with critical injuries needing immediate treatment; this clearly jeopardizes their survival [15]. In the Myyrmanni case, 3 severely injured patients (out of 13) were not triaged to the main trauma hospitals, i.e., the undertriage frequency was 23%. The 11 patients triaged to the main trauma hospitals (out of 21; 52%), were not severely injured which is in accordance with the everyday overtriage percent in a trauma hospital [15]. Thus there was no disaster-induced overtriage, in this case. The overall mortality in the Myyrmanni bombing disaster was low: 4% of all injured. This is a typical pattern for open-air bombing disasters. The bomb exploded in a very large open space inside the shopping center with rapid dissipation of the shock to open air. The building did not collapse. Building collapse is an important prognostic variable in increasing mortality in bombing disasters [15]. The critical mortality rate (excluding one death on arrival) was low: only 8%. This is apparently a consequence of the successful triage at the scene and the successful implementation of the disaster plan as well as skilful surgery. In addition, the location of the shopping center in the Helsinki Metropolitan area (16 km from the Helsinki City Centrum) with excellent transport connections contributed significantly to the success of the operation, because various authorities were able to channel rapidly a vast amount of resources to the scene of the incident.
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The chief medical commander (E.H.) in the Töölö trauma unit managed the co-operation between the surgical departments of the six involved hospitals. He gathered all patient information and informed the authorities and dealt with the media. We found this kind of concentrated information protocol very clear and effective. Although the operation was carried out successfully in terms of the end results, there is room for improvement in the activities carried out by various authorities. The proposals presented by the national investigation group focuses on improving and ensuring communication and developing the role and rights of medical helicopter services. A new digital radio network for the Finnish Authorities (VIRVE network) has been developed to promote the cooperation of different authority organizations under all circumstances in the future. Successful triage at the scene, rapid transportation of patients and good overall management of the operation proved that the Helsinki and Uusimaa area disaster plan is realistic and works in practice. The plan is rehearsed annually. The disaster exercises have concentrated on airplane accidents that would produce mostly mechanically injured and burn patients. Most patients in the Myyrmanni bombing disaster also had mechanical injuries. Although mechanical injuries predominate in the possible disasters also in the future, management of other disaster types should also be trained to ensure maximal safety of the citizens.
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Acknowledgments We thank Detective Sergeant Antti Syrjäaho, Finnish National Bureau of Investigation, for giving us access to the victim investigation reports.
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Address for Correspondence Markus Torkki, MD Department of Orthopedics and Traumatology Töölö Hospital, Helsinki University Hospital P.O. Box 26600029 HUS Helsinki Finland Fax (+358/9) 47187350 e-mail:
[email protected]
European Journal of Trauma 2006 · No. 4 © Urban & Vogel