Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study

Injuries caused by defensive bullet launchers and resource utilization during the French yellow vests protests: A retrospective study

BACKGROUND

In 2018, the French "Yellow Vest" social protest movement spread with weekly demonstrations resulting in confrontations between protesters and law enforcement. Non-lethal weapons, such as defensive bullet launchers (DBL) were used, and significant injuries have been reported through media, leading to public controversy regarding their use. These injuries are not well-known to civilian emergency physicians. The aim of this study is to describe the injuries caused by DBL among Emergency Department (ED) patients during these demonstrations and to identify the characteristics that required specialized care and hospital admission.

METHODS

A multicenter retrospective study was conducted in 7 EDs of academic hospitals in Paris, France. Adult ED patients who presented with DBL injuries during "yellow vest" strikes between November 2018 and May 2019 were included. The primary outcome was the rate of DBL patients requiring hospital admission. We also compared the characteristics of the injuries and the care provided between the admitted patients and other DBL patients.

RESULTS

152 patients were included. 17% were admitted to hospital, with 19% of them being transferred to intensive care units. 49% of all patients had head, face, eye or neck injuries including 4 cases of intracranial hemorrhage, 1 carotide dissection, 1 laryngeal edema, 1 pneumencephalus. 11% of all patients presented with multiple wounds, and 28% had fractures (77% of admitted patients vs 18%, p < 0.001). Surgery was required for 20% of all patients (62% of admitted patients vs 10%, p < 0.001). Maxillofacial surgery was performed on 38% of admitted patients, orthopedic surgery on 25%, and neurosurgery on 13%. No death were reported.

CONCLUSION

The use of DBL during the "yellow vest" civil strikes was associated with a high rate of head, face, eye or neck injuries among injured ED patients. Hospital admission was associated with a higher rate of fractures, with most of them requiring maxillofacial, orthopedic and neurosurgeries.

Lesiones mortales por armas traumáticas: reporte de caso

Introducción. Las armas de energía cinética son diseñadas para generar lesiones dolorosas y superficiales. Sin embargo, las lesiones asociadas causan confusión al ser abordadas como heridas por proyectil de arma de fuego, convirtiendo el enfoque y el manejo correcto en un desafío. El caso presentado describe un paciente herido en el cuello por arma traumática con el objetivo de analizar factores que permitan identificar este tipo de heridas y sus implicaciones en el manejo. Caso clínico. Paciente masculino de 31 años que ingresó con intubación orotraqueal, remitido de una institución de nivel 2, con herida por aparente proyectil de arma de fuego con trayectoria transcervical. Se encontró hemodinámicamente estable, pero con dificultad para la valoración clínica, por lo que se realizaron exámenes complementarios que descartaron lesión aerodigestiva. La tomografía de cuello reportó proyectil alojado en musculatura paravertebral izquierda, descartando trayectoria transcervical. Discusión. El comportamiento de las lesiones asociadas a los proyectiles de armas depende de varios factores, como el tipo de material del proyectil, su velocidad y las propiedades del tejido impactado. Se presentó un caso en que inicialmente se sospechaba una lesión transcervical, pero con la evaluación se identificó el proyectil cinético en la musculatura paravertebral. Conclusión. En el abordaje de un paciente con sospecha de herida por proyectil de arma de fuego se debe considerar ante todo la respuesta clínica y la correlación del supuesto vector del proyectil con las lesiones sospechadas. La evaluación imagenológica permite identificar oportunamente los proyectiles y evitar procedimientos o terapias innecesarias que forman parte del manejo convencional del paciente con trauma penetrante.

Management algorithm of external fixation in lower leg arterial injury for limb salvages

Purpose

The aim of this study is to investigate the outcome of these limb-threatening injuries through external fixation treatment and to discuss the case of patients’ functional recovery after external fixation.

Methods

Demographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery.

Results

Eighty-eight patients were identified and 80 patients (90 legs) maintained a successful lower leg salvage. The mean age was 32.7 ± 10.8 years, and 81.8% were male. The primary outcomes included the following complications: pin-tract infection (8 legs), pins loosening (4 pins), wound superficial infection (7 legs), deep infection developed osteomyelitis (3 legs), bone nonunion or bone defect (17 legs) and amputation (8 legs). The average healing time of fracture was 5.6 ± 4.3 months. The maintain of external fixation average time was 5.8 ± 3.6 months. The improvement of scores of the pain, function and quality of life in our follow-up was statistically significant.

Conclusion

For the lower extremity fracture patients with vascular injuries, using external fixation correctly can improve clinical outcomes and produce the improvement of pain, function and the quality of life.

Level of evidence

Retrospective cohort, level IV.

The success rate of the lower leg salvage is high, reach the percentage of 91.8% (90/98).

External fixation is less invasive, with achieving adequate stability to repair the arterial injury timely, can lower the ischemic time, and beneficial for the following bone or soft tissue repair.

Treating the patients with external fixators timely is beneficial to the following vascular anticoagulation, bone defect and vein graft, as a result, the protection of lower limb can be improved.

Effects of 2019's social protests on emergency health services utilization and case severity in Santiago, Chile: a time-series analysis

Background

On October 18th, 2019, protestors gathered across Chile to call for social equity, resulting in widespread civil unrest and violent confrontation with the police. In this study, we quantify the effects of the 2019 Chilean protests on emergency health services utilization and inpatient admission in Santiago.

Methods

We used weekly emergency department (ED) admissions (2015-2019) from three large public hospitals near the focal point of protests in Santiago. The exposure period was from October 18th to December 31st, 2019. The outcomes were the number of weekly consultations and hospitalizations by trauma and respiratory causes and the proportion of hospitalizations among consultants per 1,000. We implemented Bayesian structural time series models to calculate the absolute and relative effects and 95% credible intervals (CrI).

Findings

During the first ten weeks of protests ED consultations declined on average by 14% for trauma (95%CrI: -40·2%, 11·5%) and 30% for respiratory causes (95%CrI: -89·4%, 30·2%), 7% for respiratory hospitalizations (95%CrI: -43·6%, 30·8%); however, none of these three results were statistically distinguishable from the null. Trauma hospitalizations, on the other hand, increased by 15% (95%CrI: 4·0%, 26·4%), and the proportion of hospitalizations per consultations increased by 40% for trauma (95%CrI: 13·1%, 68·0%) and 59% for respiratory causes (95%CrI: 29·4%, 87·9%).

Interpretation

The 2019 Chilean protests affected the use of emergency health services by increasing the trauma hospitalizations and the case hospitalization ratio per 1,000 consultations for trauma and respiratory causes. Crowd-control protocols must be reviewed to prevent the negative effects of civil unrest.

Rubber Bullet Induced Traumatic Brain Injury

ABSTRACT

Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

Penetrating deep pelvic injury due to "less-lethal" beanbag munitions: a case report and policy implications

“Less-lethal” munitions are designed to cause incapacitation and are often used by law enforcement officers. Although these munitions are not designed to cause severe injury, recent reports have demonstrated that they can cause severe injury, permanent disability, and death. The long-term consequences of injury due to less-lethal munitions are not well understood. We present a case of osteomyelitis and pelvic abscess secondary to a retained beanbag munition following penetrating injury in the setting of a patient with delayed presentation for care. The patient underwent surgical removal of the retained beanbag munition and irrigation and debridement of the osteomyelitis and pelvic abscess with an excellent functional outcome. We discuss the public health and policy implications of serious injury due to less-lethal munitions.

Riots in Beirut: Description of the Impact of a New Type of Mass Casualty Event on the Emergency System in Lebanon

INTRODUCTION

In the summer of 2015, Beirut experienced a garbage crisis that led to rioting. Riot control measures resulted in multiple casualties. This study examines injury patterns of riot victims presenting to the emergency department of a tertiary care center in a developing country.

METHODS

A retrospective study was conducted in the emergency department of the American University of Beirut Medical Center between August 22 and August 30, 2015. Patients seen in the emergency department with riot injuries were included. Patient characteristics, injuries, and resources utilized in the emergency department were analyzed.

RESULTS

Ninety-five patients were identified. Most patients presented to the emergency department within a short time period. The mean age of the patients was 28.0 ± 8.7 years. Most (90.5%) of the patients were males and 92.6% were protestors. Emergency medical services were utilized by 41.0% of patients. Laceration was the most common presenting complaint (28.5%), and blunt trauma was the most common type of injury (50.5%). The head/face/neck was the most common injured body region (55.8%). Most patients did not require blood tests or procedures (91.6% and 61.0%, respectively), and 91.2% of patients were treated in the emergency department and discharged. One patient required intensive care unit admission and another was dead on arrival.

CONCLUSIONS

Most patients had mild injuries on presentation. The emergency department experienced a high influx of patients. Complications and deaths can occur from seemingly nonlethal weapons used during riots and warrant effective prehospital and hospital disaster planning.

About a pediatric facial trauma

Less-lethal weapon are more and more used in law enforcement to neutralize combative individuals and to disperse riot crowds. Even if this type of weapon has been created to be less damaging than classical firearms, it has been incriminated many times in cases of facial injuries with functional consequences, even death. In many countries, these guns can be possessed by average citizens. They could be extremely harmful when handled by inexperienced users and cannot be considered solely as defense weapons. Interestingly, little literature is available concerning facial injuries caused by the less-lethal weapons. We report the case of a ballistic wound on a 3-year-old child.

Femoral vessel injury by a nonlethal weapon projectile

Rubber projectiles are used as an alternative to metal bullets owing to their lower morbidity and mortality rate. There are few reports of vascular lesions of extremities caused by rubber projectiles in the literature. The authors report the case of a 37-year-old man who was the victim of a penetrating injury to the left thigh with a rubber projectile. He reported only pain at the site of the injury; pulses were decreased in the affected limb. After arteriography confirmed an injury to the superficial femoral artery, he underwent an arterial and venous femorofemoral bypass using a reversed contralateral saphenous vein.

Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review

OBJECTIVE

We conducted a systematic review of the available literature on deaths, injuries and permanent disability from rubber and plastic bullets, as well as from bean bag rounds, shot pellets and other projectiles used in arrests, protests and other contexts from 1 January 1990 until 1 June 2017.

DATA SOURCES

PubMed, Scopus, JSTOR and grey literature.

DATA SYNTHESIS

We report on descriptive statistics as well as data on injury severity, permanent disability and death. We analysed potential risk factors for injury severity, including the site of impact, firing distance and access to medical care.

RESULTS

Of 3228 identified articles, 26 articles met inclusion criteria. These articles included injury data on 1984 people, 53 of whom died as a result of their injuries. 300 people suffered permanent disability. Deaths and permanent disability often resulted from strikes to the head and neck (49.1% of deaths and 82.6% of permanent disabilities). Of the 2135 injuries in those who survived their injuries, 71% were severe, injuries to the skin and to the extremities were most frequent. Anatomical site of impact, firing distance and timely access to medical care were correlated with injury severity and risk of disability.

CONCLUSIONS

Kinetic impact projectiles (KIPs), often called rubber or plastic bullets, are used commonly in crowd-control settings. We find that these projectiles have caused significant morbidity and mortality during the past 27 years, much of it from penetrative injuries and head, neck and torso trauma. Given their inherent inaccuracy, potential for misuse and associated health consequences of severe injury, disability and death, KIPs do not appear to be appropriate weapons for use in crowd-control settings. There is an urgent need to establish international guidelines on the use of crowd-control weapons to prevent unnecessary injuries and deaths.

THORAX INJURY CRITERIA ASSESSMENT THROUGH NON-LETHAL IMPACT USING AN ENHANCED BIOMECHANICAL MODEL

Ballistic injury refers to the interaction of a projectile and the human body, resulting in penetration or blunt trauma. In order to consider both consequences, a hydrodynamic elastoplastic constitutive law was implemented in a numerical FE model of the human torso to simulate soft tissues behavior and to evaluate their injury risk. This law, derived from 20% ballistic gelatin, was proven to be very efficient and biofidelic for penetrating ballistic simulation in soft tissues at very high velocity. In this study, the ability of the hydrodynamic law to simulate blunt ballistic trauma is evaluated by the replication of Bir et al.’s (2004) experiments, which is a reference test of the literature for nonpenetrating ballistic impact. Lung injury criteria were also investigated through the Bir et al.’s experiments numerical replication. Human responses were evaluated in terms of mechanical parameters, which can be global (acceleration of the body, viscous criteria and impact force) or local (stress, pressure and displacement). Output results were found to be in experimental corridors developed by Bir et al., and the maximum pressure combined with the duration of the peak of pressure in the lungs seems to be a good predictor for lung injury.

A Special Collaborative Information System and Its Application in Kinetic Energy Impact

Although the benefits of the non-lethal kinetic energy projectiles are numerous, there is a need to assess the projectiles to assure their expected functions. In order to overcome the limitations of current research, a special collaborative information system based on Hybrid III 50th percentile male dummy (hybrid III dummy) was developed and validated to assess and predict the risk of non-lethal kinetic energy impact. Two types of non-lethal kinetic energy projectiles were used to attack the thorax region of the dummy surrogate at six levels of distance. Not only the sensors inside the dummy as a mechanics information system recorded all the kinetic energy impact measures accurately and effectively, but also other systems like acquiring and processing information system including hardware and software played their roles respectively. The acceleration response, displacement response showed consistent patterns with the kinetic energy measures. The results showed that the measurement from the special system was reliable for non-lethal kinetic energy projectiles. The maxima of displacement, viscous criterion (VC) and kinetic energy were both lower than correlative injury thresholds. Current study provided an alternative method to assess the performance of the non-lethal kinetic energy projectiles.

Facial fractures caused by less-lethal rubber bullet weapons: case series report and literature review

PURPOSE

The present study aims to describe three cases of patients inflicted by rubber bullets with severe facial fractures.

METHODS

In addition, a review of English-language literature involving facial fractures by rubber bullets from 1975 to 2016 was performed.

RESULTS

This current study demonstrated that the use of the LLRBW is unsafety even when applied by police enforcements exclusively.

CONCLUSIONS

Management of facial fractures caused by LLRBW is done in a usual manner with closed or open reduction associated with bone mini-plates or reconstruction plates when indicated. Special initial wound care should be done to avoid secondary infection and additional procedures.

Head injury assessment of non-lethal projectile impacts: A combined experimental/computational method

The main objective of this study is to develop a methodology to assess this risk based on experimental tests versus numerical predictive head injury simulations. A total of 16 non-lethal projectiles (NLP) impacts were conducted with rigid force plate at three different ranges of impact velocity (120, 72 and 55m/s) and the force/deformation-time data were used for the validation of finite element (FE) NLP. A good accordance between experimental and simulation data were obtained during validation of FE NLP with high correlation value (>0.98) and peak force discrepancy of less than 3%. A state-of-the art finite element head model with enhanced brain and skull material laws and specific head injury criteria was used for numerical computation of NLP impacts. Frontal and lateral FE NLP impacts to the head model at different velocities were performed under LS-DYNA. It is the very first time that the lethality of NLP is assessed by axonal strain computation to predict diffuse axonal injury (DAI) in NLP impacts to head. In case of temporo-parietal impact the min-max risk of DAI is 0-86%. With a velocity above 99.2m/s there is greater than 50% risk of DAI for temporo-parietal impacts. All the medium- and high-velocity impacts are susceptible to skull fracture, with a percentage risk higher than 90%. This study provides tool for a realistic injury (DAI and skull fracture) assessment during NLP impacts to the human head.

Severe craniocerebral trauma with sequelae caused by Flash-Ball® shot, a less-lethal weapon: Report of one case and review of the literature

The use of Flash-Ball® as a non-lethal weapon by several special units within the police and police forces started in France in 1995. Little literature is available concerning injuries caused by Flash-Ball® shooting. However, we report the case of a healthy 34-year-old male victim of a Flash-Ball® shooting during a riot following a sports event. This young man presented serious craniocerebral injuries with a left temporal fracture, moderate cerebral oedema, fronto-temporal haemorrhagic contusion along with an extra-dural hematoma and subarachnoid hemorrhage requiring neurological and rehabilitation care for two months leaving important sequelae. Although the risk is obviously lower than with firearms, Flash-Ball® is nonetheless potentially lethal and may cause serious physical injuries, particularly after a shot to the head.

Pattern of rubber bullet injuries in the lower limbs: A report from Kashmir

PURPOSE

Rubber bullets are considered a non-lethal method of crowd control and are being used over the world. However the literature regarding the pattern and management of these injuries is scarce for the forensic pathologist as well as for the traumatologist. The objective of this report was to add our experience to the existing literature.

METHODS

From June 2008 to August 2010 the Government Hospital for Bone and Joint Surgery Barzulla and the Department of Orthopaedics, SKIMS Medical College/Hospital Bemina Srinagar received 28 patients for management of their orthopaedic injuries caused by rubber bullets. We documented all injuries and also recorded the management issues and complications that we encountered.

RESULTS

All patients weremales with an age range of 11e32 years and were civilians who had been hit by rubber bullets fired by the police and the paramilitary forces. Among them, 19 patients had injuries of the lower limbs and 9 patients had injuries of the upper limbs. All patients were received within 6 h of being shot.

CONCLUSION

Our findings suggest that these weapons are capable of causing significant injuries including fractures and it is important for the surgeon to be well versed with the management of such injuries especially in areas of unrest. The report is also supportive of the opinion that these weapons are lethal and should hence be reclassified.

All Eyes on Egypt: Islam and the Medical Use of Dead Bodies Amidst Cairo's Political Unrest

Using dead bodies for medical purposes has long been considered taboo in Egypt. Public health campaigns, physicians' pleas, and the urgings of religious scholars all failed to alter public opinion regarding the donation of dead bodies either for instructional material or for therapeutic treatments. Yet in 2011, amid revolutionary turmoil in Egypt, a campaign was launched for people to donate their eyes upon death; this time, people readily signed up to be donors. Focusing on mass eye trauma that occurred in Egypt amid the political uprisings of 2011, I raise questions about when and why Islam can explain people's attitudes and behaviors, particularly toward death and medicine. The case of mass eye trauma in Egypt and citizens' reformulations of questions once jealously controlled by state-aligned doctors, politicians, and religious scholars unsettles the boundaries between 'religion' and 'secularism' in medical practice. [Formula: see text].

Police shootings against civilians in Portugal: Contextual, forensic medical and judicial characterization

The aim of this study was to analyse the circumstances, the forensic assessment and the legal assessment of police shootings of civilians, according to the severity of the victim's injuries. Sixty-nine cases tried in Portuguese criminal courts were analysed. Of the 32 cases that resulted in death, 16 were on the public thoroughfare and 13 were in the victim's vehicle or in third-party vehicles. The majority of the lethal cases occurred when the region of the body hit was the thorax/abdomen. The firearm most frequently used was a semi-automatic 9 mm pistol. In cases resulting in death police officers involved were convicted whilst those involved in non-lethal cases were acquitted. The results of this study can be taken into account by Portuguese authorities for the implementation of policies that will allow the restriction of firearms use by police officers to situations of imminent danger of death or serious injury and that will make it possible to avoid shooting at fleeing civilians.

Investigation of Deaths Temporally Associated with Law Enforcement Apprehension

The investigation of a death that occurs in custody requires a careful and methodical approach since concerns of police or institutional misconduct may be raised. The medicolegal official charged with the investigation and ultimate certification of death bears heavy responsibility to the decedent's family, the public, law enforcement and other institutions. A wide variety of causes of death and manners of death are seen in these deaths. This paper reviews causes, mechanisms, manners, findings, and evaluation of persons who have died in temporal relation to legal apprehension.

Risks of non-lethal weapon use: case studies of three French victims of stinger grenades

The development of non-lethal weapons started in the 1960s. In France, they have been used by the police for about 10 years. We relate the cases of three French women, victims of stinger grenades, non-lethal weapons recently adopted by the French law enforcement to distract and disperse crowds. The three victims presented serious injuries requiring emergency surgical care. One lost her eye. Based on these cases, we discuss the lethal character of these weapons and propose measures to be taken to prevent their dramatic consequences. Although the danger is obviously less than for firearms, stinger grenades are nonetheless potentially lethal and cause serious physical injuries.

Enucleation and evisceration in the palestinian territories

Purpose:

To examine the demographics and indications in patients undergoing eye removal at St. John Eye Hospital (SJEH) in Jerusalem, the largest single provider of ophthalmic care in the Palestinian Territories.

Materials and Methods:

In this retrospective study, medical records were reviewed for patients undergoing enucleation or evisceration at SJEH from November 2004 to March 2007. Calculation of percentage, mean and median was performed for the demographics, and indications for enucleation and evisceration.

Results:

Thirty-three eyes of 32 patients were removed during the period under study. Twelve enucleations and 21 eviscerations were performed. Mean age was 39 years, and 19 patients were male. Indications included severe trauma (8 eyes), painful blind eye with (5 eyes) or without (9 eyes) infection, and ophthalmic neoplasm (3 eyes).

Conclusion:

The incidence of surgical eye removal at SJEH from 2004 to 2007 was around one patient per month for a population over three million. This rate appears far lower than those reported in previous studies of similar Palestinian populations. Prompt access to medical care for Palestinians is required to mitigate ophthalmic morbidity. Approximately half of the cases were caused by severe trauma or infection, with rubber bullet injuries responsible for 20% of the traumatic cases.

Blunt Criterion trauma model for head and chest injury risk assessment of cal. 380 R and cal. 22 long blank cartridge actuated gundog retrieval devices

BACKGROUND

Blunt ballistic impact trauma is a current research topic due to the widespread use of kinetic energy munitions in law enforcement. In the civilian setting, an automatic dummy launcher has recently been identified as source of blunt impact trauma. However, there is no data on the injury risk of conventional dummy launchers. It is the aim of this investigation to predict potential impact injury to the human head and chest on the basis of the Blunt Criterion which is an energy based blunt trauma model to assess vulnerability to blunt weapons, projectile impacts, and behind-armor-exposures.

METHODS

Based on experimentally investigated kinetic parameters, the injury risk of two commercially available gundog retrieval devices (Waidwerk Telebock, Germany; Turner Richards, United Kingdom) was assessed using the Blunt Criterion trauma model for blunt ballistic impact trauma to the head and chest.

RESULTS

Assessing chest impact, the Blunt Criterion values for both shooting devices were higher than the critical Blunt Criterion value of 0.37, which represents a 50% risk of sustaining a thoracic skeletal injury of AIS 2 (moderate injury) or AIS 3 (serious injury). The maximum Blunt Criterion value (1.106) was higher than the Blunt Criterion value corresponding to AIS 4 (severe injury). With regard to the impact injury risk to the head, both devices surpass by far the critical Blunt Criterion value of 1.61, which represents a 50% risk of skull fracture. Highest Blunt Criterion values were measured for the Turner Richards Launcher (2.884) corresponding to a risk of skull fracture of higher than 80%.

CONCLUSION

Even though the classification as non-guns by legal authorities might implicate harmlessness, the Blunt Criterion trauma model illustrates the hazardous potential of these shooting devices. The Blunt Criterion trauma model links the laboratory findings to the impact injury patterns of the head and chest that might be expected.

Severe facial rubber bullet injuries: less lethal but extremely harmful weapons

Less-lethal rubber-bullet weapons are designed to induce blunt injuries that incapacitate violent individuals.

AIM AND SCOPE

We intend to study the functional and aesthetic impairments and the cost in terms of social health resulting from rubber-bullet facial trauma.

MATERIALS AND METHODS

We retrospectively collected all the facial trauma cases caused by mass-appeal, less-lethal guns followed up in two French university hospitals since the year 2000. We did not consider the facial injuries caused by professional, less-lethal, rubber or plastic bullet guns.

CONCLUSION

We showed that mass-appeal, less-lethal rubber-bullet guns induce severe traumas with irreversible functional consequences and long-term social implications. Victims of facial rubber-bullet traumas should be managed like high-energy trauma patients and benefit from extremely careful primary wound care.

Rubber bullet injury: case report with autopsy observation and literature review

Rubber bullets are one of the less-lethal (nonlethal) weapons, which are increasingly used to incapacitate dangerous individuals, avoiding use of firearms. An autopsy examination of a man who was shot with improved rubber bullets revealed that the bullet caused pulmonary contusion. The bullet was 30 g in weight and consisted of a sponge foam nose with 40-mm diameter and a plastic body. He was not incapacitated and died of suicidal gunshot wound. The case raised a question as to how severe an injury is necessary to deter a person without causing death. A variety of rubber bullets have been used in the world, and they have occasionally produced severe or lethal injuries. A review of the literature demonstrated that the feature of injuries appeared to be related to the type of missile. It becomes more important for a forensic pathologist to be familiar with rubber bullets and injuries caused by them as the use of less-lethal weapon increases.

Penetrating injury to the chest by an attenuated energy projectile: a case report and literature review of thoracic injuries caused by "less-lethal" munitions

We present the case of a patient who sustained a penetrating injury to the chest caused by an attenuated energy rubber bullet and review the literature on thoracic injuries caused by plastic and rubber "less-lethal" munitions. The patient of this report underwent a right thoracotomy to extract the projectile as well as a wedge resection of the injured lung parenchyma. This case demonstrates that even supposedly safe riot control munition fired at close range, at the torso, can provoke serious injury. Therefore a thorough investigation and close clinical supervision are justified.

Leadership as a component of crowd control in a hospital dealing with a mass-casualty incident: lessons learned from the October 2000 riots in Nazareth

INTRODUCTION

Crowd control is essential to the handling of mass-casualty incidents (MCIs). This is the task of the police at the site of the incident. For a hospital, responsibility falls on its security forces, with the police assuming an auxiliary role. Crowd control is difficult, especially when the casualties are due to riots involving clashes between rioters and police. This study uses data regarding the October 2000 riots in Nazareth to draw lessons about the determinants of crowd control on the scene and in hospitals.

METHODS

Data collected from formal debriefings were processed to identify the specifics of a MCI due to massive riots. The transport of patients to the hospital and the behavior of their families were considered. The actions taken by the Hospital Manager to control crowds on the hospital premises also were analyzed.

RESULTS

During 10 days of riots (01-10 October 2000), 160 casualties, including 10 severely wounded, were evacuated to the Nazareth Italian Hospital. The Nazareth English Hospital received 132 injured patients, including one critically wounded, nine severely wounded, 26 moderately injured, and 96 mildly injured. All victims were evacuated from the scene by private vehicles and were accompanied by numerous family members. This obstructed access to hospitals and hampered the care of the casualties in the emergency department. The hospital staff was unable to perform triage at the emergency department's entrance and to assign the wounded to immediate treatment areas or waiting areas. All of the wounded were taken by their families directly into the "immediate care"location where a great effort was made to prioritize the severely injured. In order to control the events, the hospital's managers enlisted prominent individuals within the crowds to aid with control. At one point, the mayor was enlisted to successfully achieve crowd control.

CONCLUSIONS

During riots, city, community, and even makeshift leaders within a crowd can play a pivotal role in helping hospital management control crowds. It may be advisable to train medical teams and hospital management to recognize potential leaders, and gain their cooperation in such an event. To optimize such cooperation, community leaders also should be acquainted with the roles of public health agencies and emergency services systems.

Injury pattern of the Flash-Ball, a less-lethal weapon used for law enforcement: report of two cases and review of the literature

Less-lethal weapons are used in law enforcement to neutralize combative individuals and to disperse riot crowds. Local police recently used such an impact weapon, the Flash-Ball, in two different situations. This gun fires large rubber bullets with kinetic energies around 200 J. Although it is designed to avoid skin penetration, impacts at such energies may still create major trauma with associated severe injuries to internal organs. This is a report of 2 patients shot with the Flash-Ball who required medical attention. One could be discharged quickly, but the other required hospitalization for heart and lung contusion. Both patients required advanced investigations including computed tomography (CT) scan. The medical literature on injuries induced by less-lethal impact weapons is reviewed. Impacts from the Flash-Ball can cause significant injury to internal organs, even without penetration. Investigations as for other high-energy blunt traumas are called for in these cases.

Medical Management of the Traumatic Consequences of Civil Unrest Incidents

In the context of this review, civil unrest is defined as disharmony, expressive dissatisfaction and/or disagreement between members of a community, which leads to a situation of competitive aggression that may find expression as disruption of organisation, conflicts, damage to property and injuries. Such a breakdown of harmonious relationships, which may result in property damage and human injuries that may be threatening to life, varies in magnitude from participation of a very few individuals up to the involvement of large crowds of people, which may evolve into a full-scale riot. It is the latter situation often involving demonstrators, opposing groups and law enforcement personnel that can result in multiple casualties and present a very significant challenge to the resources of local healthcare institutions. The causation of civil unrest incidents is multifactorial and has generic, specific and potentiating elements. With the current national and international societal, political and discriminatory problems, it is likely that civil unrest incidents on both small and large scales will continue to occur at a high and possibly increasing rate on a worldwide basis, and for these not infrequent incidents, the medical community should be in a state of informed preparation. The circumstances of civil unrest incidents are very variable with respect to causation, overall magnitude, frequency, timing, geographical location, numbers of persons involved, demographics of participants, influence of extremists, confrontation with opposing groups and control measures used by law enforcement agencies. Methods used by police and security forces for the control of civil unrest incidents, if advanced negotiations with organisers and verbal warnings have failed, fall basically into two categories: physical and chemical measures. Physical methods include restraint holds, truncheons, batons, mounted horses, projectiles (such as bean bags, plastic and rubber bullets), water cannons, tasers and (rarely) live ammunition. All of these physical measures are associated with pain and immobilisation, and there is a high potential for soft tissue and bone injuries. Some of the more severe physical methods, including plastic and rubber bullets, may cause lethal injuries. The basis for using chemicals in civil unrest incidents is that they cause distraction, transient harassment and incapacitation, temporary impairment of the conduct of coordinated tasks and cause a desire to vacate the area of unrest. Although screening smokes and malodors have sometimes been employed, the major group of chemicals used are peripheral chemosensory irritants (PCSIs), which reversibly interact with sensory nerve receptors in exposed skin and mucosal surfaces, resulting in the production of local uncomfortable sensations and associated reflexes. Major effects are on the eye, respiratory tract and (to a lesser degree) skin. Thus, the induced transient pain and discomfort in the eye, respiratory tract and skin, together with associated lacrimation, blepharospasm, rhinorrhoea, sialorrhoea, cough and breathing difficulties, produce temporary incapacitation and interference with the conduct of coordinated tasks, and form the basis for harassment of malefactors. Currently used peripheral chemosensory irritants are 1-chloroacetophenone, 2-chlorobenzylidene malononitrile, dibenz(b.f)-1,4-oxazepine, oleoresin capsicum and pelargonic acid vanillylamide. Depending on operational circumstances, irritants may be dispersed as a smoke, powder cloud, aerosol, vapour, or in solution; the mode of generation and dispersion of irritant can influence hazard. Brief acute exposure to chemosensory irritants produces effects that generally resolve within an hour, leaving no long-term sequelae. However, sustained exposure to high concentrations may produce tissue injury, notably to the eye, respiratory tract and skin. With solutions of sensory irritants, other formulation constituents may enhance PCSI toxicity or introduce additional local and/or systemic toxicity. By the very circumstances of civil unrest incidents, injuries are inevitable, particularly when emotions are heightened and police and security forces have to resort to various chemical and/or physical means of control. Trauma may include slight to severe physical and/or chemical injuries, psychological problems and occasional deaths. Hospitals should be prepared for a wide range of casualties, and the fact that those seeking help will constitute a heterogeneous group, including wide age range, male, female, and individuals with pre-existing ill health. A major civil unrest incident necessitates that the local receiving hospital should be prepared and equipped for decontamination and triage processes. It is necessary to reassure patients who have been exposed to sensory irritants that the signs and symptoms are rapidly reversible, and do not result in long-term sequelae. With respect to chemical exposures, detailed evaluation should be given to possible ocular, cutaneous, respiratory and gastrointestinal effects. Also, exposure to chemosensory irritants results in transient increases in blood pressure, bradycardia and increased intraocular pressure. This indicates that those with cardiovascular diseases and glaucoma may be at increased risk for the development of complications. This article details the pharmacological, toxicological and clinical effects of chemicals used in civil disturbance control and discusses the management of contaminated individuals. Additionally, the potential for adverse effects from delivery systems and other physical restraint procedures is summarised. Due to the emergency and specialised circumstances and conditions of a civil unrest incident, there is a clear need for advanced planning by healthcare institutions in the event that such an incident occurs in their catchment area. This should include ensuring a good information base, preparations for medical and support staff readiness, and availability of required equipment and medications. Ideally, planning, administration and coordination should be undertaken at both local (regional) and central (governmental) centres. Regional centres should have responsibilities for education, training, ensuring facilities and staffing are appropriate, and that adequate equipment and medicines are available. There should be cooperative interactions and communications with local police and other emergency services. Centrally directed functions should include ensuring adequacy of the information base, coordinating activities and agreeing approaches between the regional centres, and periodic audits of regional centres with respect to the staffing, facility, equipment and training needs. Also, there is a need for most countries to introduce detailed guidelines and formal (regulatory) schemes for the assessment of the safety-in-use of chemicals and the delivery systems that are to be used against heterogeneous human populations for the control of civil unrest incidents. Such regulatory approval schemes should also cover advisory functions for safe use and any required restrictions.

Biomechanically Based Criteria for Rib Fractures Induced by High-Speed Impact

Biomechanically based correlations for rib fractures induced by high-speed impact were developed from animal studies, finite-element simulations, and statistical analysis. Using subject-specific finite-element models of swine thorax developed from medical images and customized for each animal subject, simulations were conducted for animal tests. The peak motions, internal forces, stresses, and strains were calculated for individual ribs. Statistical analysis then was used to determine represented variables that were statistically significant and that better fit the test data. The findings showed that the main loading modes during impacts are local bending and shearing. Stress-based variables fit the injury data very well. Strains also were relevant, but did not correlate with the data as well as stresses. The results also indicate that motion responses, such as displacement and velocity, and internal forces are not good correlates in high-speed impacts. The regression risk curves were developed using the stresses as correlates, and the threshold values are given consistent with bone strength data.

Design and Injury Assessment Criteria for Blunt Ballistic Impacts

BACKGROUND

Less-lethal technologies are used in situations where lethal force is not warranted; however, a variety of injuries have been reported. Design and injury criteria are needed to assess the safety of these munitions.

METHODS

Injury data from ballistic impacts of cadavers were analyzed to validate design and injury criteria. Logistic regression analysis determined the predictive ability of the blunt criterion (BC) for munition design and the viscous criterion (VC) for injury risk assessment. Differences in risk for men and women were determined.

RESULTS

For a 50% risk of Abbreviated Injury Scale 2 or 3 thoracic injury, BC = 0.37 (chi = 17.71, p = 0.001) and VCmax = 0.8 m/s (chi = 11.28, p = 0.001). The 5th percentile female subject has a 36% lower tolerance to ballistic energy than the 50the percentile male subject.

CONCLUSION

The BC can be used in the development of kinetic energy munitions and the VC for testing impact injury risk. These criteria provide much needed tools for the development and progression of less-lethal munitions.