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Orthopaedists faced unfamiliar trauma injuries after London terrorist attacks
Surgeons performed amputations, foreign body removal and heavy prophylactic treatment.
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GLASGOW – On July 7, 2005, surgeons in London treated severe trauma injuries typically only seen on a battlefield.
Through a coordinated terrorist attack, four suicide bombers injured 700 people and killed 54 during rush hour on the London transportation system.
Designated as the primary receiving hospital, the Royal London Hospital admitted 194 patients to its accident and emergency (A&E) department that day, the largest number of central London receiving hospitals, according to specialist registrar Danyal H. Nawabi, MRCS.
An hour and a half after the bombs detonated, three double-decker buses – each carrying about 80 victims – arrived outside the Royal London A&E department.
Surgeons at the hospital, led by the orthopaedic department quickly sprung into action, clearing more than 160 beds, mobilizing resuscitation therapy and turning the fracture clinic into a treatment center for the walking wounded.
“The key here was that we had a multidisciplinary consultant team in A&E, streamlining very important management decisions, particularly towards limb salvage,” Nawabi said at the British Orthopaedic Association Annual Congress. He was one of the orthopaedic surgeons at the Royal London Hospital during the attacks.
Images: Nawabi DH |
Injuries never seen before
Royal London surgeons saw 174 walking wounded patients, and assessed and discharged most of them in the same day, Nawabi said. The A&E department admitted 27 patients and seven required care from the intensive treatment unit (ITU).
Patients presented with embedded foreign bodies, blast lung injury, mangled lower limbs and multiple severely contaminated fragment wounds – forcing surgeons to recommend amputation.
“Indeed most of us working at the hospitals saw injuries we had never seen before,” Nawabi said.
Most of the patients were part of the rush hour crowd and were an average of 34 years old.
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The victims presented with a median Injury Severity Score (ISS) of 6 and a mean ISS of 12. Surgeons associated a score below 25 with low mortality, and only five patients exceeded an ISS of 25. “This proportion of five critically injured patients out of 190 survivors is far less than expected when compared with previous terrorist incidences,” Nawabi said.
Most of the 54 deaths occurred at the bombing sites. Of the 27 ITU patients, one died from blast lung injury on the operating table and another died from head injury complications 9 days after the attacks.
Operations performed
Surgeons treated all patients according to the principles of the International Society of the Red Cross, Nawabi said. In the A&E department, they assessed wounds for degree of contamination and salvageability, and removed any foreign or dead material.
After the attacks, Royal London surgeons performed 11 primary limb amputations in seven patients, nine limb fasciotomies, five laparotomies and one sternotomy.
Thirty-eight of the walking wounded patients (20%) presented with tympanic membrane ruptures, a primary marker for blast lung injury, Nawabi said.
“It was our policy on that day to keep these patients in the hospital for at least 6 hours to observe [potential] early development of acute lung injury. Thankfully, none developed that,” Nawabi said.
Amputations
Senior orthopaedic and vascular surgeons made decisions for amputation early, although they attempted limb salvage in most situations, Nawabi said.
“When amputation was decided upon, we performed guillotine amputations, as this was a quick procedure and left the wound open for further inspection and debridement.”
Twenty-nine percent of the amputees died, compared to the 60% mortality rate among patients with traumatic amputations in the Madrid and Israeli bombings, Nawabi said.
Surgeons administered heavy prophylaxis to all infected patients, including five patients with allogenic bone particles embedded in their tissue. They have added this practice to the hospital’s major incidence protocol since then.
Removed foreign material
Those patients who underwent removal of foreign or dead material returned to the operating theatre every 48 hours.
“As compared to other reports in the literature, the 48-hour [observation] usually revealed these were still being heavily contaminated,” Nawabi said. “A number of these patients were having to go back to the theatre about five times before the wounds were deemed clean enough.”
Because of this protocol, surgeons performed most of their work in the 2 weeks after the attacks with 64 theatre operations over 183 hours.
Nawabi and his colleagues at the Royal London Hospital urged management to set aside money for extra theatre sessions in the case of a similar incident.
“We feel our response made a direct impact on the effects of the terrorist actions,” Nawabi said.
For more information:
- Nawabi DH, Lau SPK, Mann HA, et al. 7/7 bomb attacks: The Royal London Hospital experience. #114. Presented at the British Orthopaedic Association Annual Congress. Sept. 27-29, 2006. Glasgow.
- Danyal H. Nawabi, MRCS, specialist registrar, Colchester General Hospital, Turner Road, Colchester, Essex CO4 5JL, England; +44-206-747474; danyalnawabi@gmail.com.