Back to basics: managing gunshot injuries in East Timor

BACKGROUND

The management of patients following severe trauma requires a combination of skills. Among these are accurate clinical assessment, basic resuscitation measures, basic general surgical skills and techniques, good decision making and team leadership. More technically advanced imaging and investigations are often useful and can enhance clinical assessment but should not replace the basic elements. In situations where more advanced investigations are not available good outcomes can be achieved by application of the basic principles in trauma management and surgery. This article describes a mass casualty situation of gunshot wounds managed with limited resources and the outcomes.

METHODS

A series of gunshot wounds managed in a single day at Dili National Hospital, Dili, East Timor is described. The presentation of the patients, initial assessment of injuries and haemodynamic stability are detailed in addition to the subsequent surgical treatment, complications and outcomes. The information was obtained from hospital records and personal recollection of the treating doctors. All injuries were documented with digital photography. All patients were managed by two surgeons who also supervised their postoperative course and reported on their outcomes. Surgical procedures on all of the patients were performed by the named two consultant surgeons and one basic surgical trainee.

RESULTS

Fourteen patients were treated for gunshot injuries. All were single bullet injuries. Six trajectories involved the thoracic or abdominal cavity (one trajectory traversed both). Eight injuries were to limbs or soft tissue of the pelvis and included four compound fractures. Surgical intervention was needed for all patients ranging from emergency laparotomy for haemodynamic instability through to wound debridements. Thirteen patients survived and were discharged from hospital within 3 weeks. One patient died of uncontrolled haemorrhage.

CONCLUSIONS

In the present series of gunshot injuries managed with limited resources a good outcome was achieved with the application of basic principles. The present series emphasizes the importance of basic trauma management as outlined in courses such as Emergency Management of Severe Trauma and the use of basic surgical techniques as taught during the Advanced Surgical training program.

Pre-election insecurity in Afghanistan hampers health service delivery

It's three years since the fall of the Taliban; now, with an election looming, Afghanistan's battle is for better health

Injury patterns related to use of less-lethal weapons during a period of civil unrest

This case series documents injury patterns related to beanbag and other less-lethal (LL) weapons during a period of civil unrest in a major U.S. city. A retrospective review of injuries related to LL weapons usage presenting to an urban Emergency Department (ED) from April 10, 2001 to April 18, 2001 was performed. Patients under 18 years of age and those without signed consent to treat were excluded. Twenty-seven patients were identified. Two were excluded due to lack of signed consent for treatment. Mean age was 28.4 +/- 11.7 years; 76% of patients were male. Significant morbidity was found in 7 (28%) cases with no fatalities. Three (12%) individuals, with the diagnoses of pulmonary contusion, liver laceration, and Achilles tendon rupture, required admission. Two (8%) individuals had delayed complications of pneumonia and post-concussive syndrome. Reports of injury patterns associated with beanbag munitions in the medical literature are limited. Physicians should be aware of the injuries and delayed sequelae associated with their use.

[Gun-shot wounds of the face under conditions of local and boundary conflicts]

Analysis of the incidence, types, and severity of maxillofacial wounds inflicted during local and boundary conflicts showed increased incidence of the most severe wounds with injuries to both jaws. The efficiency of medical care rendered to victims with facial wounds is determined by the level of specialized training of nurses and physician's assistants.

The impact of political conflict on moral maturity: a cross-national perspective

This cross-national study of moral reasoning among adolescents in Northern Ireland, Scotland and the Republic of Ireland, addresses the problem of possible moral truncation in Northern Ireland due to the political conflict. The Sociomoral Reflection Measure-Short Form (SRM-SF; Gibbs et al. (1992) Moral Maturity: Measuring the Development of Sociomoral Reflection. Englewood Cliffs, NJ: Erlbaum. was presented to a proportionate stratified sample of 14-15 year olds (n = 613) from three locations including a small town, large town and city in each country to control for urbanization. This adolescent sample consisted of participants from both of Northern Ireland's religious communities and was matched for age and sex. Analysis of the results suggested that despite the violent atmosphere over the last 30 years, the Northern Irish adolescents were not developmentally delayed in moral terms as previously feared (Fraser (1972) Special Education,61, 6-8; Fields (1973). A Society on the Run: A Psychology of Northern Ireland. Harmondsworth, Middlesex: Penguin; (1976) Northern Ireland: Society Under Siege. New Brunswick and London: Transaction Books; Lyons (1973) The Northern Teacher, 19-30)

Vulnerability to homicide in Karachi: political activity as a risk factor

BACKGROUND

Previous studies analysing Karachi ambulance data from 1993 to 1995 identified neighbourhoods in Karachi disproportionately affected by homicide. As a step toward developing intervention programmes to curb violence, we conducted a study to identify risk factors for becoming a homicide victim in a high violence area of Karachi.

METHODS

We interviewed families of 35 cases, individuals intentionally killed through acts of violence between January 1994 and January 1997, and 85 community-based controls frequency matched by sex, from Orangi, a high violence area of Karachi.

RESULTS

Most of our cases and controls were male (97% and 92%, respectively) and had similar socioeconomic and ethnic backgrounds. All the victims were killed by firearms; 4 (11%) had been tortured prior to death. Most of the victims were killed in the streets (n = 25, 71%). Of these, 7 (36%) had been killed by law-enforcement officers, while 6 (24%) died from indiscriminate firing. People who were killed were 34 times more likely to have attended all political processions (29% versus 1%, odds ratio [OR] = 34; 95% CI: 4-749, P < 0.001), 19 times more likely to have attended political meetings (31% versus 2%, OR = 19; 95% CI: 4-136, P < 0.001), and 17 times more likely to have held an important position in a political party (29% versus 2%, OR = 17; 95% CI: 3-120, P < 0.001) than controls.

CONCLUSIONS

Homicide in Orangi was political. Efforts to improve trust between ethnic groups and to build legitimacy for non-violent forms of conflict resolution are important steps to limit future violence.

Modeling civil violence: an agent-based computational approach

This article presents an agent-based computational model of civil violence. Two variants of the civil violence model are presented. In the first a central authority seeks to suppress decentralized rebellion. In the second a central authority seeks to suppress communal violence between two warring ethnic groups.

Acid House and Thatcherism: noise, the mob, and the English countryside

This paper examines why the late 1980s youth subculture Acid House provoked a moral panic of the scale and intensity that it did. The subculture is conceived as presenting a disruptive presence to Thatcherism as an hegemonic project. The terms under which this occurred are examined through the themes of noise, the mob, and the disruption of bureaucratic authority. The presence of Acid House within the English countryside, and in particular the Home Counties, is situated as enhancing the problematic status of the subculture. The scale of measures taken against Acid House is related to Thatcherism's 'authoritarian populism'. Acid House is located in terms of a history of similar forms of popular cultural activity. The coverage of Acid House in The Sun and The Daily Mail, and the parliamentary debate around the second reading of the Entertainments (Increased Penalties) Act, are drawn upon throughout.

Landmine injuries and rehabilitation for landmine survivors

There is a tremendous international need for the development of rehabilitation educational programs, especially in low-income countries. These programs are most urgently needed in those countries where there is active conflict, where there has been recent civil war, and where significant casualties have been created because of landmines and weapons-fire. Most of these countries are developing nations where rehabilitation is a lower priority than the provision of basic health needs. These countries generally have few financial, personnel, and system resources to provide much rehabilitation for their disabled citizens. Also, they generally have few, if any, physicians trained in the principles and practice of rehabilitation medicine. These countries can benefit from the use of psychiatric consultants to help assess their rehabilitation needs in designing relevant educational curricula for health professionals and in developing rehabilitation teams. These teams can then develop systems of care for the most common disabling conditions in that area of the world. Western technology, however, cannot be imposed on these countries. Any rehabilitation systems of care must be established within the context of the particular culture and governmental health system organization, if it is to be useful and succeed in a particular nation.

Interpretations of the past and expectations for the future among Israeli and Palestinian youth

This study was developed by a group of Israeli and Palestinian researchers for the purpose of examining social knowledge of young people in the conflicted region of the Middle East. The article examines the relations between measures of interpretations of the past (perceptions of legitimacy and emotional reactions toward the historical "narratives" of Israelis and Palestinians) and measures of expectations of the collective future, as reflected in conflict resolution beliefs. Data were collected from December 1999 to February 2000 (before the present crisis [2000-2002] in Jewish-Palestinian relations) among representative samples of high school students (Grades 10 and 12): 1,183 Palestinians in the Palestinian National Territories and 1,188 Israeli Jewish students. The results are discussed from developmental, social, and cultural perspectives.

Trauma in war and political persecution: expanding the concept

A contextual understanding of the concept of trauma is proposed through a study of its meaning in a Latin American context facing war and political repression. This article explores the contributions of narrative and liberation psychology to understanding politically based trauma. It critiques the relationship between the concept of trauma and the diagnosis of posttraumatic stress disorder. It analyzes how Colombian human rights activists make sense of the political persecution and trauma in their work. The author argues that the kind of experiences that these activists have endured go beyond the category of stress and can best be understood as traumatic within the context of the current medium-intensity war in Colombia.

DOTS-based tuberculosis treatment and control during civil conflict and an HIV epidemic, Churachandpur District, India

OBJECTIVE

To pilot the WHO guidelines on DOTS for tuberculosis (TB) among displaced people affected by conflict in Churachandpur District, Manipur State, north-east India, which has endured an HIV epidemic, injecting drug use, civil unrest, high levels of TB, and poor TB treatment and prevention services for many years.

METHODS

Prerequisites for TB control programmes were established. WHO guidelines and protocols were adapted for local use. Outreach workers were appointed from each ethnic group involved in the conflict, and training was conducted. Quality control and evaluation processes were introduced.

FINDINGS

TB was diagnosed in 178 people between June and December 1998. Of the 170 with pulmonary disease, 85 were smear-positive. Successful outcomes were recorded in 91% of all patients and in 86% of smear-positive cases of pulmonary TB. The default rate and the mortality rate were low at 3% each. HIV positive serostatus was the only factor associated with a poor treatment outcome.

CONCLUSION

TB treatment and control were possible in a conflict setting and WHO targets for cure were attainable. The factors associated with the success of the programme were strong local community support, the selection of outreach workers from each ethnic group to allow access to all areas and patients, the use of directly observed therapy three times a week instead of daily in the interest of increased safety, and the limiting of distances travelled by both outreach workers and patients.