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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 132-137

Experiences and challenges of managing mass casualty during industrial action in Aminu Kano Teaching Hospital, Kano


1 Department of Surgery, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Anaesthesiology, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Community Medicine, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication14-Sep-2018

Correspondence Address:
Dr. Bashir Yunusa
Department of Surgery, Bayero University, Aminu Kano Teaching Hospital, Kano PMB 3011
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_7_18

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  Abstract 


Introduction: A mass casualty incident (MCI) is an infrequent event that requires coordinated action under time constraints. With the emergence of Boko Haram, coupled with industrial disharmony and recurrent strike actions among health workers; there were series of terrorist's attacks when either the Doctors or other health-care providers were on strikes. Objective: The aim of this study is to determine the pattern of injuries, presentation-intervention interval and the challenges of mass casualty management. Methods: This was a retrospective study among 37 multiply injured patients of suicide bombing and shooting who were admitted at Aminu Kano Teaching Hospital from 28th November 2014 to 5th February 2015. Their case notes were retrieved, information obtained includes types of the injuries and intervention among others which were analysed using SPSS version 16. Results are presented in tables and figures. Results: There were a total of 194 patients who presented to the accident and emergency unit of the hospital. The mean age (±standard deviation) was 33.4 ± 19.25 years. Twenty (10%) were dead on arrival, 37 (20%) had major injuries. More than half of the victims were operated within 6 h of presentation. About 78% had single system injuries, whereas 22% had multiple organ system injured. Up to 25% had at least two units of blood transfused. Conclusion: We were able to intervene in 3% of patients within the first 3 h of presentation and another 30% within 6 h. We would have done better if there were no industrial disputes.

Keywords: Blast injuries, industrial disputes, mass casualty


How to cite this article:
Yunusa B, Aji SA, Mashi SA, Abdullahi M, Abubakar MK, Sheshe AA, Abdullahi LB, Ismail H, Inuwa IM, Atiku M, Bello MM. Experiences and challenges of managing mass casualty during industrial action in Aminu Kano Teaching Hospital, Kano. Niger J Basic Clin Sci 2018;15:132-7

How to cite this URL:
Yunusa B, Aji SA, Mashi SA, Abdullahi M, Abubakar MK, Sheshe AA, Abdullahi LB, Ismail H, Inuwa IM, Atiku M, Bello MM. Experiences and challenges of managing mass casualty during industrial action in Aminu Kano Teaching Hospital, Kano. Niger J Basic Clin Sci [serial online] 2018 [cited 2018 Dec 11];15:132-7. Available from: http://www.njbcs.net/text.asp?2018/15/2/132/241162




  Introduction Top


A mass casualty incident (MCI) is an infrequent event that requires coordinated action under time constraints. In the past few years, besides natural disasters, transportations and structural failure incidents, terrorist bombings have emerged to be a particularly devastating and medically challenging type of an MCI.[1] The sudden influx of patients seeking similar medical interventions stretches the already inadequate critical hospital facilities and resources. Moreover, due to a variety of human and natural factors, such events have been occurring with increasing frequency and with increasingly devastating consequences.[2],[3]

Disasters can be defined as a natural or human-made event that leads to large-scale destruction of life and property resulting in permanent changes to human society and environment and untold suffering which require extraordinary response usually from outside the affected area.

The term MCI refers to disasters that involve many people.[4],[5] The frequency of disasters and MCIs is increasing, and calamities always involve mass casualties because they are unpredictable.

According to UN report, from 1994 to 2005, the world witnessed over 67,000 deaths and 260 million people wounded yearly due to disasters.[6] An estimated loss of U$204 billion occurred due to natural disasters in the 1980s.[7] Disasters and MCIs consume local resources in the short-term and long-term, and therefore, appropriate preparation is required to avoid high death and failure rates in such cases.

The 1995 Oklahoma City bombing, the 2004 Madrid train bombing and the explosion of 11th September 2001 in the New York have revealed the capacity of bombings and blast to kill and terrify.[8] The terrorist bombing in London on 7th July, 2005, produced the largest mass casualty event in the UK since world war.[9] There were 775 casualties and 56 deaths, 53 at the scene. Fifty-five patients were triaged to priority and dispatched 20 patients were critically injured. Critical mortality was low at 15% and not due to poor availability of resources as there were optimised resources to both pre- and in-hospital response. Over-triage rates were reduced where advanced pre-hospital teams did initial scene triage.[9],[10],[11]

Recurrent industrial action across all sectors of the economy is a major problem in Nigeria over the years. The health sector has witnessed its own share of industrial disharmony and recurrent strike actions. The Nigerian public hospitals had been repeatedly shut down in the past 4 years due to industrial actions by health workers leaving patients and victims with no other options than to seek for an alternative. With the emergence of Boko Haram sect, there were series of terrorists' attacks when either the Doctors or other health-care providers were on strikes. The lack of functioning disaster team which coordinates activities as well as lack of any special training or rehearsals on handling disaster in the majority of public hospitals in recent past has made the management of MCI a big challenge.

The day of 28th November 2014 witnessed one of the major suicide bombings in Kano, Nigeria, targeting the public in Friday prayer grounds within the densely populated ancient city of Kano. The multiple bomb explosions and shootings resulted in one of the biggest MCI ever recorded in the city. There were about 500 dead and more than 1000 injured victims according to an official report. This was preceded by a similar attack on the general public in January 2012, after many of such attacks in the North-Eastern cities of Nigeria.

There was an industrial actions by the joint health staff union in the biggest federal teaching hospital in the state capital, where services were virtually non-functioning, this lead to some Samaritan to take victims to the state hospitals where either or both the trained personnel and facilities to handle disaster were not available. Not until after about 3 h of negotiation with the union leaders to allow their members to cooperate after which the announcement of opening the teaching hospital casualty was made, and patients/victims were rushed.

This study aimed at determining the types of injuries, location, severity and time of presentation, as well as a presentation to intervention interval. It also assesses the challenges encountered.


  Methods Top


We retrospectively reviewed the records of all victims of suicide bombing and weapon shooting who were admitted at Aminu Kano Teaching Hospital, Kano, on Friday 28th November 2014.

The management protocol highlighted that each admitted patient was delegated to a resident surgeon and an anaesthesiologist/Intensive Care Unit resident who accompanied the patient throughout the initial evaluation and into the operating room if required. Every 3–4 patients were assigned an attending surgeon who supervised the process of triage and the initial evaluation and treatment. Medical students on surgical postings were mobilised to help in records, and minor procedures such as catheterisation, distribution of drugs and intravenous access.

Data collection

Data were retrieved from medical records. The charts of all patients admitted to the hospital with the diagnosis of trauma were reviewed and demographic data such as gender, age, ethnic group, occupation, the cause of trauma and types of injuries and their location as well as severity. Time of presentation after the injury was also noted.

The records database was screened for patients who had physical injuries and were admitted to the hospital following the Friday mosque attacks.

Data analysis

Patients bio-data information were recorded using a simple proforma, other information on the location and severity of injury was obtained dividing the body into six areas (head and neck, ocular, facial, chest, abdomen, musculoskeletal (to include back, extremities, bruises and burns), we added the sum of injured areas and defined it as the system injured' (range of 1–6). Using the cut-off of two body areas injured and defined it as 'multiple injury'

Data were entered into Microsoft excel spreadsheet and then exported into SPSS Version 16 (University of Bristol Information Services, UK, October, 2008) for Windows for analysis. Qualitative variables were summarised using frequency and percentage while quantitative variables were summarised using mean and standard deviation or median range as the case may be.


  Results Top


There were a total of 194 patients who presented to the accident and emergency unit of the hospital, 20 (10%) were dead on arrival, 37 (20%) had major injuries, while the remaining 137 (70%) had minor injuries and were treated and discharged on the day of the presentation. The available records that were analysed were for the 37 who had major injuries.

The mean age of the patients was 33.4 ± 19.25 years, whereas the age group is depicted in [Table 1]. More than half of the victims are in the age group of 21–40, while about a quarter is in the range of 0–20. Least is the group of 81–100 years.
Table 1: Age distribution

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The victims were all males, Muslims and Hausa/Fulanis.

The mean time of arrival to the hospital in hours was 2.7 ± 0.96 h. [Figure 1] shows the distribution of the time of arrival of the victims to our facility. More than half presented within 3 h while about 40% were brought within 2 h. Least was those brought at 1 and 5 h.
Figure 1: Time of arrival to the hospital

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The time of surgical intervention after arrival to the emergency room is shown [Table 2]. More than half of the victims were operated within 6 h of presentation.
Table 2: Time of surgical intervention

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The distribution of the nature of injuries based on a number of systems involved is shown in [Figure 2]. About 78% had single system injuries while 22% had multiple organ system injuries.
Figure 2: Distribution of nature if injuries

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[Table 3] shows the level of the intervening surgeons and anaesthetists. About 30% of interventions were by consultants, 49% by senior registrars while the rest were by registrars. About 9% were performed by consultants, 41% by senior registrars while almost half were by registrars. Those with minor injuries required only local anaesthesia and were given by the operating surgeons.
Table 3: Level of specialization of the surgeons and anaesthetists

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Majority of the patients did not require a blood transfusion. About a quarter of had at least one pint transfused each as depicted in [Table 4].
Table 4: Transfusion requirement and body systems injured

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Musculoskeletal was most commonly affected, accounting for 62% of the cases, this was followed by the abdomen (14%) as shown in [Table 4].

The types of surgical intervention performed are shown in [Table 5]. Out of the 37 patients that were managed by surgical intervention, only one (2.7%) died, the majority of the (89%) did well and were discharged without permanent disability. The outcome was generally good.
Table 5: Interventional procedures performed in isolation/combinated and patients' outcome

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  Discussion Top


The mean age was 33.41 ± 19.25. Majority of victims were in the age groups of 0–60 years, indicating the young to middle age being the bulkiest of our population and more likely to attend prayer grounds, and in keeping with the median age of 35 years of victims of Jakarta bomb blast as reported by Chim et al.[12],[13],[14],[15] The age groups are wide because it cuts across all the age groups from a minimum of 4 years to a maximum of 81 years. This may be because all age groups attend Friday prayers according to Islamic rights.

We found all the victims to be males and belong to Hausa/Fulani tribe as is typical of Kano metropolitan city and their religion is Islam in keeping with the mosque attack. There were no collateral victims among passer-by as usually non-Muslim avoid the roots due to traffic during prayer times.

The mean time of arrival at the casualty room of our institution from the time of the blast was 2.730 ± 0.962 in hours. The hospital is located about 12 km from the scene of the attacks. The delays can be explained by the presence of a specialist hospital within 2 km, where victims would be rushed at first and only to come to the teaching hospital on spillage or referral from there. Moreover also the knowledge that there was an ongoing strike action of joint health workers around the time. We triaged the victims based on the general physical conditions such as external bleeding, vital signs and a patient is assigned to a group of medical workers for immediate further assessment and preparation for surgery and those considered stable by the head of triage will be in the waiting area, until any of the teams is less busy enough to review again or attention is called by the severity of pains or routine reassessment.

We neither use nor did prepare to use the standard tags of red, yellow, green, black colours which are the standard worldwide.[16] We do not have the facility or the technics of electronic triage which is claimed to be very helpful in saving maximum life,[17] we recorded only three victims who died on arrival before anything could be done. This is due to the lack of preparedness, experience in disaster management and resources There were no mass casualty preparedness drills in our centre and has been found to be very helpful in improving outcome.[18],[19]

Within 3 h of presentation, 1 (2.70%) had his intervention done. 11 (29.73%) had their initial treatments within 6 h of presentation. A further 13 (35.14%) were within 12 h. The remaining 13 (32.3%) where operated from 24 to 72 h after the presentation. Although, there is no specific trauma and mass casualty practical training of health workers as in other centres [18] and obvious lack of emergency preparedness training [20] which we ought to have had with the coming of insurgency in northern Nigeria, there was high willingness among faculties, residents and other health workers [21] which led to immediate care to the victims. The reasons for the delay in the last 32% was either due to undertriage or patients who were initially thought to be stable but only to deteriorate on observation and not due to inadequate workforce or resources.

About 29 (78.38%) of the victims sustained single system injuries, whereas 8 (21.62%) have multiple systems involved in injuries. Sustaining multiple system injury is more typical of gunshot injuries and blasts as found to 62% in the explosion and 47% of gunshot injuries.[22] We did not classify the victims based on the mechanism of injury, but the low level of those who sustained multiple injuries to our centre could be explained by the possibility of those with multiple injuries dying at the scene or being rushed to the closest hospitals and likely to receive early attention on triage due to the multiplicity of the injury.

There was serious dedication and willingness by the Hospital staff to attain to the victims, sufficient hands including faculties, residents, medical students and other health staff with 5 h before the arrival of the victims. Although we did not count the number of personnel mobilised and the exact time they arrived as reported by Shen et al.[23] where 10,630 medical workers were activated within 2 h, but the percentages of the victims treated by different levels of surgeons and anaesthetists hold to that. Eight victims (29.73%) were operated by faculty surgeons, 18 (48.65%) operated by senior registrars and 11 (21.62%) were by registrars.

Victims of blast and shootings usually sustained a various degree of injuries with some suffering combination of blast, penetrating missiles and shrapnel, blunt and burns injury and that usually require more abdominal, vascular and neurosurgical procedures compared with other forms of trauma and as well most intentional blasts tend to cause more severe injury.[24] The distribution of injuries shows a higher distribution when compared to 51.6% extremities, 24.5% torso (chest, abdomen, trunk and pelvis) and 21.8% head and neck as reported by Boonthep et al.[25] However, almost closely similar to what was obtained in Jos, Nigeria during the 2001 mass casualty according to Ozoilo et al.[26]

Majority of victims closed to the blast died instantly or on their way to the hospital, which in our environment is hardly recorded, but for those who reached the hospital and survived to our intervention, majority 19 (51.36%) had penetrating gunshot or shrapnel injury followed by blunt injuries 10 (27.02%) and burns of varying degrees 8 (21.62%), unlike 52.2% and 41.4% who sustained injuries from gunshot and attack by matches and knives, respectively.[26]

There were various interventions provided based on the multiplicity of injuries. Up to 8 (19.05%) had exploratory laparotomies, 4 (9.52%) thoracotomies and 2 (4.76%) craniotomies, 3 (7.14%) had fracture reduction with or without fixation. Twenty-five (59.52%) had other interventions including enucleating an eye, maxillary fracture wiring, neck exploration and removal of shrapnel and indicated bullets. The injuries were, however, not mutually exclusive.

Only 4 (10.81%) had laparotomy alone, whereas 2 (5.41%) had a combination of laparotomy and thoracotomy and 2 (5.41%) others had laparotomy and fracture fixation. Thoracotomy alone constitutes 5.41% of the total intervention while craniotomy alone was 2.71%. Fracture reduction and fixation alone forms 8.11% while others exclusively form 59.46%. The pattern of these injuries based on its multiplicity and distribution on the parts of the body involved are in keeping with mass casualty incidences reported by Sylvain in Rwanda and Chad conflicts.[27]

The outcome of our intervention was impressive, apart from those who died on arrival before anything could be done, only one victim (2.70%) died after surgery. He suffered multiple injuries including facial, head and ocular injuries. Up to 89.19% were discharged home after successful treatment, whereas 8.11% were discharged with some disabilities. One of the victims was referred most probably due to proximity and our ability to provide all the needed care. We did not take into consideration the duration of stay in the hospital; usually, because a separate ward was provided and it did not interfere with our routine clinical work or available bed space and all resources for their treatments were paid by the government. Unlike what Peleg described in the outcome and characteristics of Israel terror-related injuries.[22]

Limitations

  1. We could not triage by international standards probably due to the lack of preparedness
  2. There was poor documentation at all levels, eyewitness could have useful and accurate information
  3. We did not grade the severity of injury based on an acceptable formula.


Recommendations

  1. The response to an MCI should be both swift and precise if it is to be effective
  2. Industrial harmonies in the health sector such be vigorously sustained
  3. Drills for disaster management should be introduced and sustained.



  Conclusion Top


Despite the industrial actions which delayed victims from coming to our facility and subsequent intervention, we were able to operate Up to 30% within the first 6 h of presentation. We would have done better, and the outcome would have been much better if there were not any of such disharmonies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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