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Gunshot injuries in Benghazi–Libya in 2011: The Libyan conflict and beyond
t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
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The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Gunshot injuries in BenghazieLibya in 2011: The Libyan conflict and beyond Zuhir Bodalal a,*, Salah Mansor a,b a b
Department of Medicine, Faculty of Medicine, Libyan International Medical University, Benghazi, Libya Department of General Surgery, Al-Jalaa Teaching Hospital, Benghazi, Libya
article info
abstract
Article history:
Background: Since independence, Libya has never experienced personal ownership of arms.
Received 3 April 2013
That changed during the Libyan conflict where weapons became widespread in the society.
Received in revised form
As a result gunshot injuries became a concern for surgeons at our principal surgical hos-
2 May 2013
pital (Al-Jalaa). This study aims at analyzing the gunshot injuries that took place during
Accepted 12 May 2013
2011 and highlighting the peculiarities in the Libyan scenario.
Available online 3 June 2013
Methods: Patient records were obtained and gunshot injuries were analyzed for various parameters. Statistical analyses were made taking into consideration situations faced by
Keywords:
neighbouring countries.
Conflict
Results: In 2011, 1761 patients were admitted with over 95% being male and over 97% were
Mortality
Libyan. The average age of a GSI patient was 28.32 10.01 years. Patients aged 18e35
Morbidity
formed over 70% of the cases with half of all cases being treated by the orthopedics
Gunshot injuries
department. Sixty-eight percent of cases were injured in the extremities followed by chest
Benghazi
(12.5%) and abdomen injuries (7.8%). The mortality rate for GSI’s was found to be 5.6%
Libya
overall with young age, site of injury (i.e. chest and head) and cause of injury (i.e. war or civilian fighting) being important risk factors. Conclusions: Taking into consideration the difficult operating conditions and limited resources, surgeons at our hospital were able to maintain a low mortality rate. Disarmament needs to begin as soon as possible because these injuries will continue to occur so long firearms are available in society. ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Libya is a North African country classified under the Eastern Mediterranean Regional Office (EMRO). In 2006, the overall population was found to be around 5.7 million with 1.6 million (28%) situated in the eastern part e the main bulk of the patients in this study are from this area. The incidence of firearm related violence is on the rise globally.1 While most nations may attribute their gunshot
injuries (GSI’s) to crime, suicide or accidents,2 the Libyan scenario is different. In February of 2011, peaceful protests against the oppressive ruling regime were attacked and a war soon broke out. As a result of the war, weapons were made available in a society that had never experienced civilian ownership of arms. In addition, local law enforcement were initially absent at the urban level and when they later returned, organizational difficulties prevented them from being effective.3
* Corresponding author. Tel.: þ218 91 478 9141. E-mail addresses: [email protected], [email protected] (Z. Bodalal). 1479-666X/$ e see front matter ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2013.05.004
259
t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
In the light of the war and absent/ineffective law enforcement, a study was done using the patient records from AlJalaa hospital for the year 2011 in order to examine the gunshot injuries that occurred e with particular emphasis on the eastern region of Libya.
Methodology Data Data was used from the Biostatistics Department of Al-Jalaa hospital in Benghazi e Libya. This hospital serves the eastern part of the country. Being the sole surgical hospital in the region, Al-Jalaa hospital receives the overwhelming majority of trauma cases in the eastern part of Libya and is therefore able to serve as a good indicator of this condition for the whole region, if not all of Libya. Any gunshot injury that occurs within the boundaries of Benghazi will immediately present to Al-Jalaa hospital (virtually all cases). As for GSI’s that took place outside of the city, any case that can’t be immediately stabilized in the field hospital or requires further medical evaluation will be referred to Al-Jalaa hospital. The study was approved by the bioethical committee at the Libyan International Medical University. The data covered all patients who were received in this hospital during 2011 (from January 1st to December 31st). A total sample size of 1761 patients who were received at the hospital due to gunshot injuries was obtained. Various parameters were observed and recorded for this year.
Statistical methods An SPSS based model was designed that spanned the collected data and basic statistical procedures were performed. These included means, standard deviations, percentage calculation, Chi-square testing, t-tests and table and chart design. Incidence rates were calculated via the direct method using population data from the 2006 Libyan census, taking into consideration the appropriate population growth. The admission data was taken for all the cases admitted to all the departments of the hospital. Furthermore, the data was filtered to include only those cases that were admitted because of gunshot injuries. The parameters under observation were age, gender, nationality, method of entry, site of injury, received under which department, admitted to the ICU or not, duration of stay, method of discharge and fatalities among other parameters.
Table 1 e The incidence of gunshot injuries during the period of peace (from 2001 to 2010) and the period of the conflict (2011). Male
Female
Overall
Year
n
Crude rate
n
Crude rate
n
Crude rate
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
65 0 48 71 60 143 35 0 39 41 1685
8.7 0.0 6.2 8.9 7.4 17.3 4.1 0.0 4.4 4.6 184.4
1 0 1 0 1 5 1 0 1 1 76
0.1 0.0 0.1 0.0 0.1 0.6 0.1 0.0 0.1 0.1 8.8
66 0 49 71 61 148 36 0 40 42 1761
4.5 0.0 3.2 4.6 3.9 9.2 2.2 0.0 2.3 2.4 98.8
over 20 times more likely to be shot during the war than a female. The average age of these patients was 28.32 10.01 years in general. The average age of female patients was 26.12 15.00 years whereas that of male patients was 28.42 9.73 years. Minors (age below 18 years) formed 7.9% (n ¼ 138), however the largest two age groups represented among patients are the 18e26 year old age group (38.5%, n ¼ 678) and the 27e35 year old demographic (34.7%, n ¼ 611). Libyan nationals formed the overwhelming majority (97.8%, n ¼ 1723) of such patients received. Figure 1 shows the number of gunshot injuries and absconded patients that took place in 2011 divided by months. Being the main trauma center in eastern Libya, Al-Jalaa hospital naturally receives cases from other surrounding areas. Sixty-eight and a half percent (n ¼ 1207) of gunshot patients were from Benghazi, whereas Al-Marj (100 km to the east), Al-Wahat (300 km to the southwest) and Misrata (800 km to the west) were the three areas that had the largest contribution (7.0%, n ¼ 124; 6.9%, n ¼ 122; 3.5%, n ¼ 61 respectively) to the patient load after Benghazi. It should be noted that the
Results In the year of 2011, Al-Jalaa hospital received 1761 patients with gunshot injuries. Among these patients, 95.7% (n ¼ 1685) were male while the remaining 4.3% (n ¼ 76) were female. This male to female ratio comes to over 22:1. Table 1 displays the incidence rate of gunshot injuries during peace time and the conflict for both males and females. In corroboration with the gender distribution, the incidence rates reflect a heavy male predominance. A male was
Fig 1 e The distribution of gunshot injuries (GSI) and absconded patients across the months of 2011. The gray bars represent the number of gunshot injuries while the black bars represent the number of absconded patients.
260
t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
numbers for Al-Wahat do not include the patients from the frontline hospitals. Around 29.6% (n ¼ 522) of the patients were referred from another hospital (either within or outside Benghazi or from the military hospitals on the front line) whereas 68.0% (n ¼ 1197) were brought in using an ambulance. Acute (emergency) presentations formed 92.2% (n ¼ 1623), on the other hand 7.8% (n ¼ 138) were non-emergency “cold” cases. The latter are either people who initially chose not to seek proper medical treatment after being shot or in fact did seek medical assistance but have returned with complications. When the cause of the injury was studied, it was observed that 37.8% (n ¼ 665) of the patient files did not state the exact circumstances in which the gunshot occurred. The remaining, valid cases (62.2%, n ¼ 1096) were either due to fighting (13.7%, n ¼ 150), stray bullets (14.1%, n ¼ 155) or the war itself (72.2%, n ¼ 791). The patients who are received at Al-Jalaa are referred by the emergency outpatient department (OPD) to particular departments based on the nature of the injury. It was observed that the Orthopedics (53.2%, n ¼ 937) department handled the majority of patients followed by General Surgery (18.2%, n ¼ 321) and the Intensive Care Unit (ICU) (11.1%, n ¼ 195). This however, only reflects the initial receiving department; occasionally, a patient may need to be moved to another department based on any changes in their state or the nature of the injury. Ultimately, 12.3% (n ¼ 217) of patients had to spend time in the ICU either initially or after having been transferred from another department. The human body was divided into 12 divisions and the frequency of injury in each segment was recorded. Out of the 1761 gunshot injuries recorded in 2011, 140 (8.0%) did not mention the site of the injury. By far, the lower limbs (comprising the thighs, legs and feet) were the most commonly affected area of the body (43.7%, n ¼ 710), followed by the upper limbs (25.2%, n ¼ 408) and chest (12.5%, n ¼ 203). The average stay of a gunshot patient in the hospital was 5.91 12.3 days. Admission was not necessary for 13.2% (n ¼ 233) of patients while the overwhelming majority (65.6%, n ¼ 1156) spent around a week in the hospital. The discharge records were examined and it was observed that 10.2% (n ¼ 180) were transferred out of the hospital (either within or outside Benghazi). Additionally, it was found that 6.5% (n ¼ 114) of patients left against medical advice (LAMA) while another 9.0% (n ¼ 159) simply absconded (ran away). March was found to be the month with the largest number of absconded patients (25.4%, n ¼ 40) e nearly double any other month. Six patients (0.3%) refused to be admitted to the hospital at all. Moreover, 5.6% (n ¼ 98) expired despite the doctors’ best efforts. The remaining (68.4%, n ¼ 1204) were treated and discharged to be followed-up on an outpatient basis. Detailed results can be found for gunshot patients (regardless of outcome) in Table 2. When the patients who had expired were taken aside and studied separately, it was noticed that average age of a fatal GSI patient was 28.7 10 years with 18e35 year old group forming 64.7% (n ¼ 66) of the cases. Minors are also over-
represented among the fatalities where they constitute 14.3% (n ¼ 14) of the deaths. Furthermore, 54.1% (n ¼ 53) had spent “0 days” in the hospital; in other words, they perished within 24 h. Another 35.7% (n ¼ 35) expired within a week of their admission (see Table 3). The average number of days spent by fatal GSI patients was 2.82 8.28 days which was significantly shorter than the other patients ( p < 0.001). The site of injury also differed in the case of the fatalities. More patients were injured as a result of chest (31.6%, n ¼ 24) and head injuries (28.9%, n ¼ 22) than any other cause. Also, 87.8% (n ¼ 86) of the fatal cases were rushed to the ICU upon arrival as opposed to the subsequent 93.9% (n ¼ 92). The majority of fatal cases were as a result of the war (59.7%, n ¼ 40) followed by random civilian (street) fighting (22.4%, n ¼ 15). Detailed results can be found for fatal gunshot patients in Table 4. When the cause of the injury was examined, it was observed that in the war, 5.1% of GSI patients died whereas when the cause was (non-military) fighting, 10.0% of patients died (see Table 5).
Discussion The massive increase in the number of gunshot injuries can be explained primarily by the outbreak of war in Libya. When compared to previous years, the average number of GSI’s was very low (especially given the fact that possession of firearms was illegal). Most were in the form of hunting accidents, police shots or very rarely criminal action. Figure 2 depicts the number of GSI’s that occurred in the decade preceding 2011. One point worth mentioning is that the significant jump in the number of GSI’s that occurred in 2006 was probably due to the government crackdown on Benghazi due to protests that took place around the Italian consulate. Otherwise, the rate of injuries was very low e there were even certain years were no GSI’s took place. Also, when looking at the incidence rates for the years leading up to the war, they were found to be very low, especially for females. The conflict caused the incidence rate to jump 40 times for males and 88 times for females compared to the year before. A very strong male predilection was observed in our study and was much higher than values stated in previous studies concerning the Nigerian civil war.4 Such a finding may be due to the fact that in most of the societies in the region, males are more active in outdoor life (either during peace time or during war). The battle field in the Libyan scenario was almost exclusively male dominated. Women and children were not actively targeted. Figure 1 showed that the months with the largest number of GSI’s were March and October. March was the period of time were most of the fighting was near Benghazi (the “Siege of Benghazi” on March 19th). The increased number of injuries in October could be explained by the renewed fighting that took place near Benghazi with the last push to liberate the city of Sirte and its surrounding areas. The significant drop in GSI’s in November and December is most likely due to the fact that Libya’s liberation was declared on October 23rd, 2011. All major military campaigns were ended and only minor
261
t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
Table 2 e Display of variables analyzed for gunshot injuries in 2011. Age (njSD) Duration (njSD)
28.32
10.019
5.91
12.301
Gender (nj%) Male Female
1685 76
95.7 4.3
Nationality (nj%) Libyan Foreigner
1723 38
97.8 2.2
Age distribution (nj%) 0e8 yo 9e17 yo 18e26 yo 27e35 yo 36e44 yo 45e53 yo 54e62 yo 63e71 yo 72e80 yo
40 98 678 611 225 70 25 10 4
2.3 5.6 38.5 34.7 12.8 4.0 1.4 0.6 0.2
Duration of stay (nj%) Under 24 h 1e7 days 8e14 days 15e21 days 22e28 days 29 þ days
233 1156 227 72 33 40
13.2 65.6 12.9 4.1 1.9 2.3
Method of entry (nj%) Ambulance Refer from Benghazi Hospital Referred from a hospital outside Benghazi
1197 42 522
68.0 2.4 29.6
Presentation (nj%) Cold case Emergency
138 1623
7.8 92.2
130 321 3 195 95 28 937 52
7.4 18.2 0.2 11.1 5.4 1.6 53.2 3.0
ICU Admissions (nj%) Not ICU ICU
1544 217
87.7 12.3
Cause of injury (nj%) Fighting Stray bullet War Total Unspecified Total
150 155 791 1096 665 1761
13.7 14.1 72.2 100.0
116 57 48 72 105 183 284 307
7.2 3.5 3.0 4.4 6.5 11.3 17.5 18.9
Receiving department (nj%) Chest surgery General surgery Hand surgery ICU Neurosurgery Oromaxillofacial Orthopedics Plastic surgery
Location of injury (nj%) Head Vertebra Shoulder Arm Forearm Hand Thigh Leg
Table 2 (continued) Foot Chest Abdomen Total (valid) Unspecified Total Method of discharge (nj%) Transferred to a hospital in Benghazi Transferred to a hospital outside Benghazi LAMA Absconded Discharged to attend OPD Expired Refuse admission
119 203 127 1621 140 1761
7.3 12.5 7.8 100.0
66 114 114 159 1204 98 6
3.7 6.5 6.5 9.0 68.4 5.6 0.3
skirmishes took place intermittently. While the war had officially ended, the rate of GSI’s were still high in the postconflict setting. This suggests the importance of the implementation of a disarmament program in the future. The young age group (from 18 to 35 years) formed 73.2% of the GSI patients. This is understandable since it is the young people who primarily participated in the war and it is the same demographic that are more likely to be involved fights or to be walking outside in times of violence (stray bullets). In fact, the average age of patients again was lower than those for most of the previous literature.4 During the conflict, large numbers of foreign nationals left the country (along with a large number of Libyans fleeing the violence). As a demographic, they did not actively participate in the war and furthermore, they weren’t targeted in the fighting. All these factors would logically lead to their underrepresentation among GSI patients. During the first four days of the conflict (from February 17th till February 20th), when the conflict took place within Benghazi, a triage system was set in place where cases were divided based on severity and multiple disciplines took part in the management (i.e. orthopedics, general surgery, nursing, physiotherapy, pharmacy etc). Afterwards, the hospital returned to its normal system of an outpatient department receiving all the cases and later referring them (i.e. admission) to the ward. Another common route of admission would be simply referral from smaller hospitals e either within the city or outside it. Al-Marj and Al-Wahat are in close proximity to Benghazi and most of their complicated cases are referred to Al-Jalaa hospital. The increased availability of arms in these rural areas and the initial lack of experience probably lead to the increased contribution to the GSI case load.
Table 3 e Outcome for patients who spent less than 24 h in the hospital. Outcome for <24 h stay (nj%) Transferred to a hospital in Benghazi Transferred to a hospital outside Benghazi LAMA Absconded Discharged to attend OPD Expired Refuse admission
30 4 19 32 90 53 5
12.9 1.7 8.2 13.7 38.6 22.7 2.1
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t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
Table 4 e Display of variables analyzed for fatal gunshot injuries in 2011. Age (njSD) Duration (njSD)
26.61
10.875
2.82
8.275
Gender (nj%) Male Female
93 5
94.9 5.1
Age distribution (nj%) 0e8 yo 9e17 yo 18e26 yo 27e35 yo 36e44 yo 45e53 yo 54e62 yo
6 8 32 34 13 4 1
6.1 8.2 32.7 34.7 13.3 4.1 1.0
Receiving department (nj%) Chest surgery General surgery ICU Neurosurgery Orthopedics
2 4 86 5 1
2.0 4.1 87.8 5.1 1.0
Cause of injury (nj%) Fighting Stray bullet War Total Unspecified Total
15 12 40 67 31 98
22.4 17.9 59.7 100.0
Location of injury (nj%) Head Vertebra Forearm Hand Thigh Leg Foot Chest Abdomen Total (valid) Unspecified Total
22 5 1 1 4 5 1 24 13 76 22 98
28.9 6.6 1.3 1.3 5.3 6.6 1.3 31.6 17.1 100.0
In general, most patients from Misrata spent very little time in Al-Jalaa hospital. They would be received and basic support was provided and within hours they would usually be sent abroad for treatment. These patients would take their
Table 5 e Comparison of outcomes between gunshot patients based on cause of injury (war or fighting). Outcome (nj%) Transferred to a hospital in Benghazi Transferred to a hospital outside Benghazi LAMA Absconded Discharged to attend OPD Expired Refuse admission Total
War
Fighting
42
5.3
8
5.3
113
14.3
0
0
39 64 491 40 2 791
4.9 8.1 62.1 5.1 0.3 100.0
12 19 95 15 1 150
8.0 12.7 63.3 10.0 0.7 100.0
Fig 2 e The number of gunshot injuries in the city of Benghazi during the past ten years (2001e2010). The black bars represent the number of gunshot injuries that took place in Benghazi.
medical files with them and hence they would not be recorded in the Biostatistics department. The low proportion of cold cases indicates that most of the injuries were not superficial or simple in nature. When medical attention was deemed to be necessary, these people were rushed more often than not by ambulance to the hospital. The field hospitals and other non-trauma hospitals also played an important role in the handling of such cases. An excellent mortality rate was observed (5.6%) especially given the nature of the injuries of the Libyan war. Credit needs to be given to the hospital and its staff for their heroic efforts and hard work. Interestingly, nearly 40% of the recorded GSI’s did not specify the cause of the wound. This may either be due to clerical errors during admission or perhaps due to hesitation (on the part of the patients) to admit the reason for being shot. When the known cases were studied separately, the war was the dominant cause of gunshots as most cases were brought in from the frontlines. One point worth noting is that stray bullets cause as many injuries as (civilian) fighting. Stray bullets injuries usually occur due to celebratory gunfire (a new tradition in the Libyan culture). The orthopedics department received more than half the cases, which is likely because 68.9% of the injuries occurred in the limbs (both upper and lower) where bone trauma is more probable. General surgeons dealt with a variety of situations either in the limbs, abdomen, chest or any other site. Vascular lesions were very common and again the surgeons handled these wounds with a high success rate. Patients admitted to the ICU received attention from members of all related departments (i.e. orthopedics and general surgery) in the cases of multiple traumas. Another positive point to the work of the staff at Al-Jalaa hospital is that only 1.2% of the cases that went to the other department had to be transferred to the ICU. A significant proportion of patients spent less than 24 h in the hospital. About one-fifth of such patients had expired while another 13% had transferred out of the hospital.
t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
On a general scale, the method of discharge was found to have a very high survival rate (over 94%). An alarming feature though was the high rate of absconded and LAMA patients. This may indicate many things such as a strong desire to return to the frontlines and defending the country (in the case of the war injuries) and fear of punishment (in the case of fighting patients). March was found to be the month with the highest number of absconded patients. This corroborates with our personal experience of the injured leaving the hospital in fear of the enemy troops invading Benghazi (especially in March) and potentially executing any hospitalized patient due to the war. An interesting point is the difference in figures between normal patients and those who ultimately expired. Chest injuries only form 12.5% of the total GSI’s however, nearly one third of fatalities were harmed in the chest. More remarkably, head injuries only formed 6.6% of total injuries however almost 30% of deaths were due to such wounds. Two studies from Benin and Nigeria found that only 3.9% and 8.2% of the fatal GSI’s occurred in the head and chest.5,6 This may indicate that in the Libyan scenario, the physicians were able to manage the limb wounds more effectively e thereby decreasing the risk of mortality. Chest injuries are problematic in the fact that quite often; the trauma is in multiple locations and may even involve the abdomen7 let alone the major vessels. Head injuries have been shown to have a high mortality rate (reaching up to 30%). This is usually in the form of cranial vault trauma as gunshots to the face are rare outside of the context of war.8 When combat injuries were studied in general, the incidence of chest injuries and injuries to the head/neck region was much higher than in our case.7 However, the proportion of cases with trauma to the extremities was very similar (around 51%). Also, there were significantly more patients that spent 24 h in the hospital (either dead on arrival or presenting with injuries incompatible with life) and overall, fewer days were spent by these patients in the hospital. Around 90% of the patients who died did so in the first week. This may be seen as the “critical period” for GSI’s and additional monitoring needs to be provided in this period of time. Previous literature mentioned that the injured to killed ratio is higher when conventional weapons are used in war as opposed to other situations.9 This was found to be true in the Libya scenario where the mortality in non-war GSI was nearly twice as high. This can be explained by a different psychological state in the two cases. In our war, the fighting mainly occurred to liberate land and cities and there were no personal issues that would encourage the fighters to kill. However, in street fights or crimes, murder is quite often the intention.
Conclusions The Libyan scenario for GSI’s is unique in that a society that was disarmed for decades. Sudden, widespread availability of
263
arms (in the context of war) caused a surge in gunshot injuries. The staff at Al-Jalaa hospital handled the vast majority of surgical cases from the eastern half of Libya and much of the western and southern parts. The majority of the patients were young men between the ages of 18 and 35 years. Most of the GSI’s occurred on the frontlines. The majority of injuries took place in the extremities (primarily dealt by orthopedic surgeons) and trunk (dealt by general surgeons). A low mortality rate was maintained despite limited resources and later drug shortages (due to international sanctions). The process of disarmament needs to begin in a systematic manner because the availability of weapons creates a constant of number of injuries and deaths that is only somewhat lower than in the conflict setting.10
Conflicts of interest and source of funding The authors state there is no conflict of interest whatsoever and no funding or support from any party was received in the making of this study.
references
1. Persad IJ, Reddy RS, Saunders MA, Patel J. Gunshot injuries to the extremities: experience of a U.K. trauma centre. Injury 2005;36:407e11. 2. Cummings P, Lemier M, Reek DB. Trends in firearm related injuries in Washington State 1989e1995. Ann Emerg Med 1998;32:37e43. 3. Bodalal Z, Bendardaf R, Ambarek M, Nagelkerke N. Road traffic accidents in Benghazi during the Libyan conflict: the impact of absent law enforcement. Traffic Inj Prev 2013 [submitted for publication]. 4. Abbas AD, Bakari AA, Abba AM. Epidemiology of armed robbery-related gunshot injuries in Maiduguri, Nigeria. Niger J Clin Pract 2012;15:19e22. 5. Udosen AM, Etiuma AU, Ugare GA, Bassey OO. Gunshot injuries in Calabar, Nigeria: an indication of increasing societal violence and police brutality. Afr Health Sci 2006;6(3):170e2. 6. Ohanaka EC, Iribhogbe EP, Ofoegbu RO. Gunshot injuries in Benin city. Nig J Surg Sc 2000;2:81e5. 7. Kristek J, Sego K, Has B. Surgical treatment of patients with penetrating chest injuries sustained in war. Med Glas Ljek Komore Zenicko-doboj Kantona 2012;9(1):56e60. 8. Pereira C, Boyd JB, Dickenson B, Putnam B. Gunshot wounds to the face: level I urban trauma center: a 10-year level I urban trauma center experience. Ann Plast Surg 2012;68(4):378e81. 9. Coupland RM, Meddings DR. Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review. BMJ 1999;319:407e10. 10. Meddings DR. Weapons injuries during and after periods of conflict: retrospective analysis. BMJ 1997;315:1417e20.
Available online at www.sciencedirect.com
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The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Gunshot injuries in BenghazieLibya in 2011: The Libyan conflict and beyond Zuhir Bodalal a,*, Salah Mansor a,b a b
Department of Medicine, Faculty of Medicine, Libyan International Medical University, Benghazi, Libya Department of General Surgery, Al-Jalaa Teaching Hospital, Benghazi, Libya
article info
abstract
Article history:
Background: Since independence, Libya has never experienced personal ownership of arms.
Received 3 April 2013
That changed during the Libyan conflict where weapons became widespread in the society.
Received in revised form
As a result gunshot injuries became a concern for surgeons at our principal surgical hos-
2 May 2013
pital (Al-Jalaa). This study aims at analyzing the gunshot injuries that took place during
Accepted 12 May 2013
2011 and highlighting the peculiarities in the Libyan scenario.
Available online 3 June 2013
Methods: Patient records were obtained and gunshot injuries were analyzed for various parameters. Statistical analyses were made taking into consideration situations faced by
Keywords:
neighbouring countries.
Conflict
Results: In 2011, 1761 patients were admitted with over 95% being male and over 97% were
Mortality
Libyan. The average age of a GSI patient was 28.32 10.01 years. Patients aged 18e35
Morbidity
formed over 70% of the cases with half of all cases being treated by the orthopedics
Gunshot injuries
department. Sixty-eight percent of cases were injured in the extremities followed by chest
Benghazi
(12.5%) and abdomen injuries (7.8%). The mortality rate for GSI’s was found to be 5.6%
Libya
overall with young age, site of injury (i.e. chest and head) and cause of injury (i.e. war or civilian fighting) being important risk factors. Conclusions: Taking into consideration the difficult operating conditions and limited resources, surgeons at our hospital were able to maintain a low mortality rate. Disarmament needs to begin as soon as possible because these injuries will continue to occur so long firearms are available in society. ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Libya is a North African country classified under the Eastern Mediterranean Regional Office (EMRO). In 2006, the overall population was found to be around 5.7 million with 1.6 million (28%) situated in the eastern part e the main bulk of the patients in this study are from this area. The incidence of firearm related violence is on the rise globally.1 While most nations may attribute their gunshot
injuries (GSI’s) to crime, suicide or accidents,2 the Libyan scenario is different. In February of 2011, peaceful protests against the oppressive ruling regime were attacked and a war soon broke out. As a result of the war, weapons were made available in a society that had never experienced civilian ownership of arms. In addition, local law enforcement were initially absent at the urban level and when they later returned, organizational difficulties prevented them from being effective.3
* Corresponding author. Tel.: þ218 91 478 9141. E-mail addresses: [email protected], [email protected] (Z. Bodalal). 1479-666X/$ e see front matter ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2013.05.004
259
t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
In the light of the war and absent/ineffective law enforcement, a study was done using the patient records from AlJalaa hospital for the year 2011 in order to examine the gunshot injuries that occurred e with particular emphasis on the eastern region of Libya.
Methodology Data Data was used from the Biostatistics Department of Al-Jalaa hospital in Benghazi e Libya. This hospital serves the eastern part of the country. Being the sole surgical hospital in the region, Al-Jalaa hospital receives the overwhelming majority of trauma cases in the eastern part of Libya and is therefore able to serve as a good indicator of this condition for the whole region, if not all of Libya. Any gunshot injury that occurs within the boundaries of Benghazi will immediately present to Al-Jalaa hospital (virtually all cases). As for GSI’s that took place outside of the city, any case that can’t be immediately stabilized in the field hospital or requires further medical evaluation will be referred to Al-Jalaa hospital. The study was approved by the bioethical committee at the Libyan International Medical University. The data covered all patients who were received in this hospital during 2011 (from January 1st to December 31st). A total sample size of 1761 patients who were received at the hospital due to gunshot injuries was obtained. Various parameters were observed and recorded for this year.
Statistical methods An SPSS based model was designed that spanned the collected data and basic statistical procedures were performed. These included means, standard deviations, percentage calculation, Chi-square testing, t-tests and table and chart design. Incidence rates were calculated via the direct method using population data from the 2006 Libyan census, taking into consideration the appropriate population growth. The admission data was taken for all the cases admitted to all the departments of the hospital. Furthermore, the data was filtered to include only those cases that were admitted because of gunshot injuries. The parameters under observation were age, gender, nationality, method of entry, site of injury, received under which department, admitted to the ICU or not, duration of stay, method of discharge and fatalities among other parameters.
Table 1 e The incidence of gunshot injuries during the period of peace (from 2001 to 2010) and the period of the conflict (2011). Male
Female
Overall
Year
n
Crude rate
n
Crude rate
n
Crude rate
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
65 0 48 71 60 143 35 0 39 41 1685
8.7 0.0 6.2 8.9 7.4 17.3 4.1 0.0 4.4 4.6 184.4
1 0 1 0 1 5 1 0 1 1 76
0.1 0.0 0.1 0.0 0.1 0.6 0.1 0.0 0.1 0.1 8.8
66 0 49 71 61 148 36 0 40 42 1761
4.5 0.0 3.2 4.6 3.9 9.2 2.2 0.0 2.3 2.4 98.8
over 20 times more likely to be shot during the war than a female. The average age of these patients was 28.32 10.01 years in general. The average age of female patients was 26.12 15.00 years whereas that of male patients was 28.42 9.73 years. Minors (age below 18 years) formed 7.9% (n ¼ 138), however the largest two age groups represented among patients are the 18e26 year old age group (38.5%, n ¼ 678) and the 27e35 year old demographic (34.7%, n ¼ 611). Libyan nationals formed the overwhelming majority (97.8%, n ¼ 1723) of such patients received. Figure 1 shows the number of gunshot injuries and absconded patients that took place in 2011 divided by months. Being the main trauma center in eastern Libya, Al-Jalaa hospital naturally receives cases from other surrounding areas. Sixty-eight and a half percent (n ¼ 1207) of gunshot patients were from Benghazi, whereas Al-Marj (100 km to the east), Al-Wahat (300 km to the southwest) and Misrata (800 km to the west) were the three areas that had the largest contribution (7.0%, n ¼ 124; 6.9%, n ¼ 122; 3.5%, n ¼ 61 respectively) to the patient load after Benghazi. It should be noted that the
Results In the year of 2011, Al-Jalaa hospital received 1761 patients with gunshot injuries. Among these patients, 95.7% (n ¼ 1685) were male while the remaining 4.3% (n ¼ 76) were female. This male to female ratio comes to over 22:1. Table 1 displays the incidence rate of gunshot injuries during peace time and the conflict for both males and females. In corroboration with the gender distribution, the incidence rates reflect a heavy male predominance. A male was
Fig 1 e The distribution of gunshot injuries (GSI) and absconded patients across the months of 2011. The gray bars represent the number of gunshot injuries while the black bars represent the number of absconded patients.
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numbers for Al-Wahat do not include the patients from the frontline hospitals. Around 29.6% (n ¼ 522) of the patients were referred from another hospital (either within or outside Benghazi or from the military hospitals on the front line) whereas 68.0% (n ¼ 1197) were brought in using an ambulance. Acute (emergency) presentations formed 92.2% (n ¼ 1623), on the other hand 7.8% (n ¼ 138) were non-emergency “cold” cases. The latter are either people who initially chose not to seek proper medical treatment after being shot or in fact did seek medical assistance but have returned with complications. When the cause of the injury was studied, it was observed that 37.8% (n ¼ 665) of the patient files did not state the exact circumstances in which the gunshot occurred. The remaining, valid cases (62.2%, n ¼ 1096) were either due to fighting (13.7%, n ¼ 150), stray bullets (14.1%, n ¼ 155) or the war itself (72.2%, n ¼ 791). The patients who are received at Al-Jalaa are referred by the emergency outpatient department (OPD) to particular departments based on the nature of the injury. It was observed that the Orthopedics (53.2%, n ¼ 937) department handled the majority of patients followed by General Surgery (18.2%, n ¼ 321) and the Intensive Care Unit (ICU) (11.1%, n ¼ 195). This however, only reflects the initial receiving department; occasionally, a patient may need to be moved to another department based on any changes in their state or the nature of the injury. Ultimately, 12.3% (n ¼ 217) of patients had to spend time in the ICU either initially or after having been transferred from another department. The human body was divided into 12 divisions and the frequency of injury in each segment was recorded. Out of the 1761 gunshot injuries recorded in 2011, 140 (8.0%) did not mention the site of the injury. By far, the lower limbs (comprising the thighs, legs and feet) were the most commonly affected area of the body (43.7%, n ¼ 710), followed by the upper limbs (25.2%, n ¼ 408) and chest (12.5%, n ¼ 203). The average stay of a gunshot patient in the hospital was 5.91 12.3 days. Admission was not necessary for 13.2% (n ¼ 233) of patients while the overwhelming majority (65.6%, n ¼ 1156) spent around a week in the hospital. The discharge records were examined and it was observed that 10.2% (n ¼ 180) were transferred out of the hospital (either within or outside Benghazi). Additionally, it was found that 6.5% (n ¼ 114) of patients left against medical advice (LAMA) while another 9.0% (n ¼ 159) simply absconded (ran away). March was found to be the month with the largest number of absconded patients (25.4%, n ¼ 40) e nearly double any other month. Six patients (0.3%) refused to be admitted to the hospital at all. Moreover, 5.6% (n ¼ 98) expired despite the doctors’ best efforts. The remaining (68.4%, n ¼ 1204) were treated and discharged to be followed-up on an outpatient basis. Detailed results can be found for gunshot patients (regardless of outcome) in Table 2. When the patients who had expired were taken aside and studied separately, it was noticed that average age of a fatal GSI patient was 28.7 10 years with 18e35 year old group forming 64.7% (n ¼ 66) of the cases. Minors are also over-
represented among the fatalities where they constitute 14.3% (n ¼ 14) of the deaths. Furthermore, 54.1% (n ¼ 53) had spent “0 days” in the hospital; in other words, they perished within 24 h. Another 35.7% (n ¼ 35) expired within a week of their admission (see Table 3). The average number of days spent by fatal GSI patients was 2.82 8.28 days which was significantly shorter than the other patients ( p < 0.001). The site of injury also differed in the case of the fatalities. More patients were injured as a result of chest (31.6%, n ¼ 24) and head injuries (28.9%, n ¼ 22) than any other cause. Also, 87.8% (n ¼ 86) of the fatal cases were rushed to the ICU upon arrival as opposed to the subsequent 93.9% (n ¼ 92). The majority of fatal cases were as a result of the war (59.7%, n ¼ 40) followed by random civilian (street) fighting (22.4%, n ¼ 15). Detailed results can be found for fatal gunshot patients in Table 4. When the cause of the injury was examined, it was observed that in the war, 5.1% of GSI patients died whereas when the cause was (non-military) fighting, 10.0% of patients died (see Table 5).
Discussion The massive increase in the number of gunshot injuries can be explained primarily by the outbreak of war in Libya. When compared to previous years, the average number of GSI’s was very low (especially given the fact that possession of firearms was illegal). Most were in the form of hunting accidents, police shots or very rarely criminal action. Figure 2 depicts the number of GSI’s that occurred in the decade preceding 2011. One point worth mentioning is that the significant jump in the number of GSI’s that occurred in 2006 was probably due to the government crackdown on Benghazi due to protests that took place around the Italian consulate. Otherwise, the rate of injuries was very low e there were even certain years were no GSI’s took place. Also, when looking at the incidence rates for the years leading up to the war, they were found to be very low, especially for females. The conflict caused the incidence rate to jump 40 times for males and 88 times for females compared to the year before. A very strong male predilection was observed in our study and was much higher than values stated in previous studies concerning the Nigerian civil war.4 Such a finding may be due to the fact that in most of the societies in the region, males are more active in outdoor life (either during peace time or during war). The battle field in the Libyan scenario was almost exclusively male dominated. Women and children were not actively targeted. Figure 1 showed that the months with the largest number of GSI’s were March and October. March was the period of time were most of the fighting was near Benghazi (the “Siege of Benghazi” on March 19th). The increased number of injuries in October could be explained by the renewed fighting that took place near Benghazi with the last push to liberate the city of Sirte and its surrounding areas. The significant drop in GSI’s in November and December is most likely due to the fact that Libya’s liberation was declared on October 23rd, 2011. All major military campaigns were ended and only minor
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Table 2 e Display of variables analyzed for gunshot injuries in 2011. Age (njSD) Duration (njSD)
28.32
10.019
5.91
12.301
Gender (nj%) Male Female
1685 76
95.7 4.3
Nationality (nj%) Libyan Foreigner
1723 38
97.8 2.2
Age distribution (nj%) 0e8 yo 9e17 yo 18e26 yo 27e35 yo 36e44 yo 45e53 yo 54e62 yo 63e71 yo 72e80 yo
40 98 678 611 225 70 25 10 4
2.3 5.6 38.5 34.7 12.8 4.0 1.4 0.6 0.2
Duration of stay (nj%) Under 24 h 1e7 days 8e14 days 15e21 days 22e28 days 29 þ days
233 1156 227 72 33 40
13.2 65.6 12.9 4.1 1.9 2.3
Method of entry (nj%) Ambulance Refer from Benghazi Hospital Referred from a hospital outside Benghazi
1197 42 522
68.0 2.4 29.6
Presentation (nj%) Cold case Emergency
138 1623
7.8 92.2
130 321 3 195 95 28 937 52
7.4 18.2 0.2 11.1 5.4 1.6 53.2 3.0
ICU Admissions (nj%) Not ICU ICU
1544 217
87.7 12.3
Cause of injury (nj%) Fighting Stray bullet War Total Unspecified Total
150 155 791 1096 665 1761
13.7 14.1 72.2 100.0
116 57 48 72 105 183 284 307
7.2 3.5 3.0 4.4 6.5 11.3 17.5 18.9
Receiving department (nj%) Chest surgery General surgery Hand surgery ICU Neurosurgery Oromaxillofacial Orthopedics Plastic surgery
Location of injury (nj%) Head Vertebra Shoulder Arm Forearm Hand Thigh Leg
Table 2 (continued) Foot Chest Abdomen Total (valid) Unspecified Total Method of discharge (nj%) Transferred to a hospital in Benghazi Transferred to a hospital outside Benghazi LAMA Absconded Discharged to attend OPD Expired Refuse admission
119 203 127 1621 140 1761
7.3 12.5 7.8 100.0
66 114 114 159 1204 98 6
3.7 6.5 6.5 9.0 68.4 5.6 0.3
skirmishes took place intermittently. While the war had officially ended, the rate of GSI’s were still high in the postconflict setting. This suggests the importance of the implementation of a disarmament program in the future. The young age group (from 18 to 35 years) formed 73.2% of the GSI patients. This is understandable since it is the young people who primarily participated in the war and it is the same demographic that are more likely to be involved fights or to be walking outside in times of violence (stray bullets). In fact, the average age of patients again was lower than those for most of the previous literature.4 During the conflict, large numbers of foreign nationals left the country (along with a large number of Libyans fleeing the violence). As a demographic, they did not actively participate in the war and furthermore, they weren’t targeted in the fighting. All these factors would logically lead to their underrepresentation among GSI patients. During the first four days of the conflict (from February 17th till February 20th), when the conflict took place within Benghazi, a triage system was set in place where cases were divided based on severity and multiple disciplines took part in the management (i.e. orthopedics, general surgery, nursing, physiotherapy, pharmacy etc). Afterwards, the hospital returned to its normal system of an outpatient department receiving all the cases and later referring them (i.e. admission) to the ward. Another common route of admission would be simply referral from smaller hospitals e either within the city or outside it. Al-Marj and Al-Wahat are in close proximity to Benghazi and most of their complicated cases are referred to Al-Jalaa hospital. The increased availability of arms in these rural areas and the initial lack of experience probably lead to the increased contribution to the GSI case load.
Table 3 e Outcome for patients who spent less than 24 h in the hospital. Outcome for <24 h stay (nj%) Transferred to a hospital in Benghazi Transferred to a hospital outside Benghazi LAMA Absconded Discharged to attend OPD Expired Refuse admission
30 4 19 32 90 53 5
12.9 1.7 8.2 13.7 38.6 22.7 2.1
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Table 4 e Display of variables analyzed for fatal gunshot injuries in 2011. Age (njSD) Duration (njSD)
26.61
10.875
2.82
8.275
Gender (nj%) Male Female
93 5
94.9 5.1
Age distribution (nj%) 0e8 yo 9e17 yo 18e26 yo 27e35 yo 36e44 yo 45e53 yo 54e62 yo
6 8 32 34 13 4 1
6.1 8.2 32.7 34.7 13.3 4.1 1.0
Receiving department (nj%) Chest surgery General surgery ICU Neurosurgery Orthopedics
2 4 86 5 1
2.0 4.1 87.8 5.1 1.0
Cause of injury (nj%) Fighting Stray bullet War Total Unspecified Total
15 12 40 67 31 98
22.4 17.9 59.7 100.0
Location of injury (nj%) Head Vertebra Forearm Hand Thigh Leg Foot Chest Abdomen Total (valid) Unspecified Total
22 5 1 1 4 5 1 24 13 76 22 98
28.9 6.6 1.3 1.3 5.3 6.6 1.3 31.6 17.1 100.0
In general, most patients from Misrata spent very little time in Al-Jalaa hospital. They would be received and basic support was provided and within hours they would usually be sent abroad for treatment. These patients would take their
Table 5 e Comparison of outcomes between gunshot patients based on cause of injury (war or fighting). Outcome (nj%) Transferred to a hospital in Benghazi Transferred to a hospital outside Benghazi LAMA Absconded Discharged to attend OPD Expired Refuse admission Total
War
Fighting
42
5.3
8
5.3
113
14.3
0
0
39 64 491 40 2 791
4.9 8.1 62.1 5.1 0.3 100.0
12 19 95 15 1 150
8.0 12.7 63.3 10.0 0.7 100.0
Fig 2 e The number of gunshot injuries in the city of Benghazi during the past ten years (2001e2010). The black bars represent the number of gunshot injuries that took place in Benghazi.
medical files with them and hence they would not be recorded in the Biostatistics department. The low proportion of cold cases indicates that most of the injuries were not superficial or simple in nature. When medical attention was deemed to be necessary, these people were rushed more often than not by ambulance to the hospital. The field hospitals and other non-trauma hospitals also played an important role in the handling of such cases. An excellent mortality rate was observed (5.6%) especially given the nature of the injuries of the Libyan war. Credit needs to be given to the hospital and its staff for their heroic efforts and hard work. Interestingly, nearly 40% of the recorded GSI’s did not specify the cause of the wound. This may either be due to clerical errors during admission or perhaps due to hesitation (on the part of the patients) to admit the reason for being shot. When the known cases were studied separately, the war was the dominant cause of gunshots as most cases were brought in from the frontlines. One point worth noting is that stray bullets cause as many injuries as (civilian) fighting. Stray bullets injuries usually occur due to celebratory gunfire (a new tradition in the Libyan culture). The orthopedics department received more than half the cases, which is likely because 68.9% of the injuries occurred in the limbs (both upper and lower) where bone trauma is more probable. General surgeons dealt with a variety of situations either in the limbs, abdomen, chest or any other site. Vascular lesions were very common and again the surgeons handled these wounds with a high success rate. Patients admitted to the ICU received attention from members of all related departments (i.e. orthopedics and general surgery) in the cases of multiple traumas. Another positive point to the work of the staff at Al-Jalaa hospital is that only 1.2% of the cases that went to the other department had to be transferred to the ICU. A significant proportion of patients spent less than 24 h in the hospital. About one-fifth of such patients had expired while another 13% had transferred out of the hospital.
t h e s u r g e o n 1 1 ( 2 0 1 3 ) 2 5 8 e2 6 3
On a general scale, the method of discharge was found to have a very high survival rate (over 94%). An alarming feature though was the high rate of absconded and LAMA patients. This may indicate many things such as a strong desire to return to the frontlines and defending the country (in the case of the war injuries) and fear of punishment (in the case of fighting patients). March was found to be the month with the highest number of absconded patients. This corroborates with our personal experience of the injured leaving the hospital in fear of the enemy troops invading Benghazi (especially in March) and potentially executing any hospitalized patient due to the war. An interesting point is the difference in figures between normal patients and those who ultimately expired. Chest injuries only form 12.5% of the total GSI’s however, nearly one third of fatalities were harmed in the chest. More remarkably, head injuries only formed 6.6% of total injuries however almost 30% of deaths were due to such wounds. Two studies from Benin and Nigeria found that only 3.9% and 8.2% of the fatal GSI’s occurred in the head and chest.5,6 This may indicate that in the Libyan scenario, the physicians were able to manage the limb wounds more effectively e thereby decreasing the risk of mortality. Chest injuries are problematic in the fact that quite often; the trauma is in multiple locations and may even involve the abdomen7 let alone the major vessels. Head injuries have been shown to have a high mortality rate (reaching up to 30%). This is usually in the form of cranial vault trauma as gunshots to the face are rare outside of the context of war.8 When combat injuries were studied in general, the incidence of chest injuries and injuries to the head/neck region was much higher than in our case.7 However, the proportion of cases with trauma to the extremities was very similar (around 51%). Also, there were significantly more patients that spent 24 h in the hospital (either dead on arrival or presenting with injuries incompatible with life) and overall, fewer days were spent by these patients in the hospital. Around 90% of the patients who died did so in the first week. This may be seen as the “critical period” for GSI’s and additional monitoring needs to be provided in this period of time. Previous literature mentioned that the injured to killed ratio is higher when conventional weapons are used in war as opposed to other situations.9 This was found to be true in the Libya scenario where the mortality in non-war GSI was nearly twice as high. This can be explained by a different psychological state in the two cases. In our war, the fighting mainly occurred to liberate land and cities and there were no personal issues that would encourage the fighters to kill. However, in street fights or crimes, murder is quite often the intention.
Conclusions The Libyan scenario for GSI’s is unique in that a society that was disarmed for decades. Sudden, widespread availability of
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arms (in the context of war) caused a surge in gunshot injuries. The staff at Al-Jalaa hospital handled the vast majority of surgical cases from the eastern half of Libya and much of the western and southern parts. The majority of the patients were young men between the ages of 18 and 35 years. Most of the GSI’s occurred on the frontlines. The majority of injuries took place in the extremities (primarily dealt by orthopedic surgeons) and trunk (dealt by general surgeons). A low mortality rate was maintained despite limited resources and later drug shortages (due to international sanctions). The process of disarmament needs to begin in a systematic manner because the availability of weapons creates a constant of number of injuries and deaths that is only somewhat lower than in the conflict setting.10
Conflicts of interest and source of funding The authors state there is no conflict of interest whatsoever and no funding or support from any party was received in the making of this study.
references
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