Emergency Medicine

Emergency service experience following the terrorist attack in Mogadishu, 14 October 2017, a scene of lay rescuer triage

a b s t r a c t

Background: A suicide bomber attack occurred in Somalia’s capital city of Mogadishu on October 14, 2017. Over 500 people died, making it the third largest suicide bombing attack in world history. In this study, we aimed to share our experience and to discuss the importance of triage and prehospital care systems.

Methods: These retrospective data included data from patients who suffered from severe explosions. Patient tri- age was performed using the START (Simple Triage and Rapid treatment) triage algorithm at the entrance of the hospital. The patients included in the study were classified according to their age, sex, triage code, location of their Major injury, department to which they were admitted, and discharge and/or exit status.

Results: The patients included 188 (74.6%) males, and the mean age was 30.94 +- 12.23 years (range, 1-80 years). Eighty-six (34.1%) patients were marked with a red code indicating major injury, and 138 (54.8%) patients had superficial injuries. A total of 173 (68.7%) patients were managed in the emergency department (ED), and 7 (2.8%) patients died in the first 24 h. Multiple trauma injuries were detected in 43 (17.1%) patients, and 31 (12.3%) patients were admitted to the orthopedics department.

Conclusion: Disaster management in a terrorist event requires rapid transport, appropriate triage, effective surgi- cal approaches, and specific postoperative care. In this event, almost all patients were brought to the ED by lay rescuers. Appropriate triage algorithms for the public can be designed; for instance, green code: walking patient; yellow code: patient who is moving and asking for help; red code: unmoving or less mobile patient who is breathing; black code: nonbreathing patient.

(C) 2020

  1. Introduction

Disasters occur suddenly and can overwhelm the community’s ca- pacity to return to a normal state. In addition to natural disasters such as floods, earthquakes and landslides, terrorist attacks are also consid- ered to be disasters [1]. Terrorism is illegal behavior in the form of ran- dom and ruthless violence, generally against innocent individuals, with the aim of intimidating the policies and ideologies of a government or community [2]. The increasing frequency of terrorist events has resulted in a growing need for emergency healthcare services and has shown that hospital Healthcare personnel and resources must be used in a pro- ductive way [2]. The morbidity and mortality of thousands of innocent victims of the ever increasing numbers of terror attacks has highlighted the importance of disaster medicine [3]. When the number of patients presenting at the same time exceeds the medical service capacity of the hospital, it is classified as a hospital disaster [4,5]. Early and

* Corresponding author.

E-mail addresses: [email protected] (M.E. Demirel), [email protected] (M. Bogan).

appropriate initiation of disaster management helps to reduce morbid- ity and mortality. The primary challenges of disaster management are triaging patients and recording data. In addition, the lack facilities for in- terventions is a problem in the ED in the first 24-48 h [6,7].

In this study, we presented our experiences in an ED after a suicide bombing attack in the Somalian capital of Mogadishu on 14 October 2017. In this event, which became the third largest suicide bombing at- tack in world history, over 500 people died and over 300 patients pre- sented to the hospital [8]. We also aimed to discuss the importance of lay rescuer triage, as almost all patients were transferred to the hospital by lay rescuers.

  1. Material and methods

For this study, ethics committee approval was obtained from the ethical board of Mogadishu Somalia-Turkey Recep Tayyip Erdogan Edu- cation and Research Hospital (Date: 25/12/2017; Decision no: 27/ MSTH/4123). The study included patients who were admitted to the ED of the Mogadishu Somalia Turkish Training and Research Hospital following the suicide bomber attack. A truck loaded with explosives

https://doi.org/10.1016/j.ajem.2020.12.005

0735-6757/(C) 2020

prehospital management“>was detonated by terrorists on October 14, 2017 in the Somalian capital of Mogadishu. Hospital records were used to obtain data for patients who were affected by the explosion.

Mogadishu is the capital of Somalia and, with a population of ap- proximately 3 million, is the most crowded city in the country. Twenty hospitals serve the people of Mogadishu, but most of these are private hospitals, so gaining access to take health care is difficult for many peo- ple. Mogadishu Somalia Turkish Training and Research Hospital and Madina Hospital provide the most affordable health care in the city, and care is free for those with the greatest need.

    1. Prehospital management

At this time, there are no prehospital emergency health services or emergency response activation systems in Somalia. There is no entity that would perform triage and carry out the organization process at the scene. Approximately 5 ambulances belong to humanitarian aid organiza- tions and can be called to the scene of a mass casualty incident or an indi- vidual emergency. These ambulances don’t have equipment and healthcare personnel; they are only utilized for the purpose of picking up patients and taking them to a health care. After the Mogadishu suicide bombing, the patients arrived in a disorganized condition; almost all of them were brought by the public with motor vehicles (named bajaaj taxi), and very few arrived by ambulance. Therefore, triage was applied at the hospital entrance within the framework of the hospital disaster plan.

    1. Triage management in the hospital
      • A triage entrance was created at hospital entry.
      • The triage officer categorized patients using the START (Simple Tri- age and Rapid Treatment) triage algorithm. However, the START triage system was modified according to the current situation, as triage was performed at the hospital door rather than at the explosion area. Triage was carried out by an emergency physician with 1 year of experience.
      • Green code (Minor injury): Patients with superficial abrasions that do not require wound care, such as saturation or debridement, walking on foot, who can carry out their self-care, and in whom worsening is not expected in the short and long term.
      • Yellow code (Moderate injury): Patients with Serious injuries whose condition is not expected to deteriorate within hours and who have stable vital signs.
      • Red code (Major injury): Patients who need immediate interven- tion (in the first 60 min) to survive and whose vital signs, airway, respi- ration and circulation (ABC) may be impaired.
      • Black code: Patients who are not expected to survive with the avail- able facilities.
      • The hospital garden was used as a triage area.

-Triage workflow.

      • Red code patients were taken to the ED, the first evaluation was performed, and they were quickly transferred to the intensive care unit and other departments. Patients requiring emergency surgery were taken to the Operating rooms.
      • Yellow code patients were taken to the ED, and they were evalu- ated after red code patients. All patients were hospitalized in relevant departments, and these patients were re-evaluated at bedside.
      • Green code patients were kept in the garden, while red and yellow code patients were re-evaluated after their treatment was planned. Most of the green code patients were discharged without any intervention.
      • Black code patients were taken to the hospital backyard, and the deceased were taken to the morgue. There were no patients with black code at first assessment.

Management in the hospital.

-Condition of the hospital on the day of the explosion.

One emergency medicine specialist and two emergency medicine residents worked in the ED, which is 1.4 km from the location of the

attack. There were 29 doctors working in the hospital at that time (one emergency medicine specialist, three anesthesiologists, two gen- eral surgeons, two neurosurgeons, one Orthopedic surgeon, one thoracic surgeon, one pediatric surgeon, one ophthalmologist, one otolaryngolo- gist, one urologist and 14 internal/basic specialist doctors such as bio- chemists, internal medicine physicians, pediatricians, neurologists, cardiologists and radiologists). The total bED capacity of the hospital is 219, including a 20-bed intensive care unit.

The first action in the hospital.

The first victims of the explosion arrived at the hospital ED approx- imately 20 min after the explosion, and they continued to arrive over a period of two hours. The hospital administration reacted to the event very rapidly and organized additional beds in the hospital wards, which was on average 70% full at that time. Elective surgical cases were cancelled, and some patients who were in good condition were discharged immediately. The 6-bed capacity yellow area, the 6-bed capacity green area, the resuscitation room, two trauma rooms and the waiting room were used for the first interventions in the ED.

In-hospital workflow.

ED interventions took place rapidly, first for red coded patients and second for yellow coded patients, and the patients were transferred to the necessary departments, ICU or operating rooms. The patients were transferred to units that were appropriate for their most significant in- juries. Two different doctor teams were established; the first team (one surgeon and one emergency specialist) detected the pathologies of the patients and transferred them urgently to other departments after the first interventions. The other team (consisting of surgeons) re-evaluated the patients in the various departments and in the ICU. Patients with an emergency clinical status were admitted for surgery, and an order of priority was established for those who needed relatively elective procedures. Patients with less severe injuries who could be followed up as outpatients were discharged after observation.

    1. Classification of the data

Patient observation charts, which are routinely used in the ED, were used as triage cards. All incoming patients at the triage entrance were identified with these cards. Patients’ triage color code, sex, age (with pa- tient statement or estimated age for nonspeaking patients), and injury site were written on the cards. All patients were numbered by writing a number in the name section on their cards. The enumerated patients were taken to the areas specified by the triage codes. The patients were registered in the hospital information management system (FONET health information systems software, 1997, Turkey) under these numbers, and all examinations and treatments performed were associated with these numbers. In Somalia, there is no identification document that identifies the citizens within the country; therefore, the identity information of the patients has been electively reorganized based on patient statements.

information transferred to the hospital information management system was evaluated retrospectively. Patients included in the study were classified according to age, sex, triage code, location of major in- jury, department to which they were admitted, and discharge and/or exit status. Patients not considered to have life-threatening priority were classified as having superficial injuries (foreign body only, burns, lacerations, and superficial foreign body). Patients with life- threatening injuries who required follow-up or surgery were classified according to the anatomic region of the lesion. Patients with at least two organ system injuries or with injuries in one organ system and two major bones were evaluated as Multiple trauma patients.

    1. Statistical analysis

Statistical analyses of these parameters were performed using SPSS vn 22.0 software. Numbers and percentage values are given for categor- ical variables as descriptive statistics.

  1. Results

The patients (total 252) included 188 (74.6%) males and 64 (25.4%) females. The overall mean age was 30.94 +- 12.23 years (range, 1-80 years), with 31.04 +- 9.71 years (range, 7-47 years) for females and 30.90 +- 13.01 years (range, 1-80 years) for males. Eighty-six (34.1%) patients were marked with a red code, and 138 (54.8%) patients had superficial injuries. Additionally, 28 (11.11%) patients were <= 18 years old. A total of 173 (68.7%) patients were managed in the ED, and 7 (2.8%) patients died in the first 24 h. Of the 79 patients who were hospitalized, mortality was seen in 4 pa- tients (5%) within the first 24 h. Multiple traumatic injuries were de- tected in 43 (17.1%) patients, and 31 (12.3%) patients were admitted to the orthopedics department (Table 1).

A total of 10 patients from our hospital were so critically injured that intervention was impossible in Somalia, so they were transferred to Turkey by Air ambulance.

Seven of the patients who had been admitted to the ED died in the first 24 h. Four of these patients underwent amputation in the ED, three of which died in the ED. The other patient died while admitted to the ICU, as did 2 additional patients without amputation. The remain- ing patient died in Turkey.

  1. Discussion

In a disaster, the number of victims exceeds the medical service ca- pacity. Various studies have reported several problems that are experi- enced by EDs in disaster situations [6,7,9]. The main problems experienced in EDs in the first hours after a disaster are problems of tri- age and records caused by the increase in Patient presentations and in- sufficient space for interventions to be made [6]. Triage performed at the site of the event is of great importance with respect to reducing the loss of work force in the ED and reducing mortality rates. Patients were transferred to the appropriate hospital according to their general status, mechanism of injury and localization of injury [10,11]. As a single

Table 1

Descriptive data of the patients

Parameter Value

Sex Male n = 188 (74.6%)

Female n = 64 (25.4%)

Age [Mean +- SD(min-max)] 30.94 +- 12.23 years (1-80)

Triage code of the Patients

hospital capacity may not be sufficient for a disaster situation, the rele- vant authorities should distribute the cases to various hospitals [12]. Triage is a process that quickly evaluates the severity of the injury and the need for medical intervention in cases with multiple injuries [13]. It also includes planning the transfer of cases to appropriate centers in terrorist attacks, wars, industrial accidents, and natural disasters. Color codes (green, yellow, red, black), scoring and descriptions (such as minor, moderate, major) are used to classify patients and strengthen communication between healthcare personnel [14]. In a disaster, triage is performed in the disaster area, and then the victims are transferred to the hospital.

In the Neve Shalom and Beth Israel Synagogue bomb attacks in Istan- bul on 15 November 2003, the majority of the 76 cases (95% of patients; Injury Severity Score < 16) admitted to a hospital were non-life- threatening injuries; the vast majority of these patients were brought by ambulance, and none of them died [15]. In the attack on the Argen- tine Israeli Mutual Association building in Buenos Aires on 18 July 1994, of the 86 cases arriving at the hospital (some by ambulance, some on foot), 58% were minor injuries, 19% were moderate injuries and 21% were Major injuries; two patients died on admission [16]. In the attack that took place in Madrid on 11 March 2004, 4 out of 5 of the 312 patients who had arrived at the hospitals had serious injuries; most of these patients were transferred to the hospital by ambulances, and two patients died on admission [17]. As can be observed in these ex- amples, although the mortality at the disaster scene was very high, the cases transferred to the hospital were mostly severe and moderate cases. With the presence of preHospital systems, planning transfers with prehospital triage applied by healthcare personnel has become common in the modern world. In our study, all patients were brought to the hospital by laypersons without undergoing prehospital evalua- tion. Although we lacked data on patients with green codes, the vast majority of cases were yellow and red codes (moderate or major in- jury), three patients died in the ED on the first admission, and no black codes had been identified; these results were all consistent with previous reports. This situation can be regarded as a natural triage by the people helping the wounded patients at the scene. Factors such as patients’ ability to walk, the level of consciousness necessary to be able to ask for help and the presence of breathing may have supported the triage performed by the public. Triage by healthcare professionals is best; however, in major disasters where there is no prehospital healthcare system or where healthcare units are insufficient, lay res- cuers naturally accompany aid activities. First aid training for lay res- cuers is widely available in many countries [18,19]. It has been reported that lay rescuers can also make accurate triage decisions [20].

Code Green? Code Yellow Code Red Code Black

body region of Injury (n,%)

Superficial injuries Upper extremity injuries Lower extremity injuries Head injuries

thoracic injuries Abdominal injuries Multiple trauma injuries Outcomes of the Patients

Management in the ED (n,%)

Discharge from ED Exit (within 24 h)

Admission to the hospital (n,%)

Orthopedics General Surgery Neurosurgery Thoracic and CVS plastic surgery

ICU Other Surgery Services

n ? 50 (unknown%) n = 166 (65.9%)

n = 86 (34.1%)

n = 0 (0.0%)

n = 138 (54.8%)

n = 19 (7.5%)

n = 9 (3.6%)

n = 31 (12.3%)

n = 6 (2.4%)

n = 6 (2.4%)

n = 43 (17.1%)

n = 173 (68.7%)

n = 166 (65.9%)

n = 7 (2.8%)

n = 79 (31.3%)

n = 31 (12.3%)

n = 11 (4.4%)

n = 12 (4.8%)

n = 4 (81.6%)

n = 1 (0.4%)

n = 13 (5.2%)

n = 7 (2.8%)

In addition to completing first aid training, we believe that lay rescuers should be given the training to determine which patient should be transferred first, and this can improve the triage performed by observa- tion, as we have stated in our study.

Approximately 75% of the patients injured in the explosion were male because the sociocultural structure of the region requires that males play a greater role in social life. One of the most significant Public health problems in the modern world is injuries that particularly affect the younger age groups, and this is a significant cause of death [21]. The mean age of the patients in this study was 30.9 years, which was similar to previous data in the literature. The mean age of male and female pa- tients was similar.

In this disaster, of the patients presenting to the ED, 7 died in the early period, and another 4 died in the first hours during follow-up. The mortality rate for patients admitted to the hospital was 4.4% of all the patients who presented to the ED. Of the 79 patients who were hos- pitalized, mortality was seen in 4 (5%). In a study by Biancolini et al., a mortality rate of 8.3% was reported in patients who were hospitalized following an explosion [16]. Gutierrez et al. reported a mortality rate of 1.6% of those who presented at the hospital following a bombing

* The patients with green codes were not admitted to the ER because of the low capacity of the hospital. Because of that, the real number of green coded patients is unknown.

[17]. The findings of the current study were similar to numbers reported in the literature for other mass casualty explosions.

Deaths in explosions, which are mass deaths, show a trimodal distri- bution. Approximately half of the deaths occur in the first minutes, gen- erally because of severe head and vascular injuries. Then, in the first hours, deaths occur in the ED and operating room due to intra- abdominal bleeding and Intracranial bleeding. Approximately 20% of deaths occur within days in the ICU, with late complications originating from severe sepsis and multiorgan failure. This Trimodal distribution has shown that emergency medicine specialists, surgeons and intensive care specialists are very important determinants in this process, espe- cially in prehospital care [22,23]. Several studies have reported that di- saster casualties have more wounds in the head and neck regions [24,25]. With a similar rate to previous findings in the literature, the pa- tients in the current study were seen to have been affected more in the head and upper extremities. This could be due to the effect of the bomb in the open air and that the injuries were caused by fragments broken from buildings or vehicles.

Of the patients who presented to the hospital, 31.3% were admitted.

In other studies, this rate has varied from 9% to 28% [11,17,26,27]. This high rate could be attributed to the transfer to our hospital of critical state patients from other hospitals in the region. When the patients who presented at the hospital were evaluated according to the depart- ments where they were admitted, although most admissions were to orthopedics, most patients required multiple surgeries. Following these types of mass terror attacks, it is expected that there will be inju- ries involving more than one surgical department. In multiple trauma situations, such as when ICU bed capacity is insufficient, it may be better to admit the patient to the department related to the system most af- fected by the major and vital findings, and other related surgical depart- ments can provide consultation.

  1. Limitations

This study was performed retrospectively, which is an important limitation. Because the number of multiple trauma patients presenting at the same time exceeded the hospital’s capacity, patient records in the hospital information management system could not be recorded in detail. In Somalia, patients do not have official identification informa- tion, so the records of patients enumerated at triage entry have been registered with names based on the declaration of the hospital informa- tion management system; this situation creates serious problems in the storage, organization and reliability of information. The education level of lay rescuers who brought the patients to the hospital is also un- known, but it is known that the education level of the general popula- tion is low.

  1. Conclusion

Disaster management following a terrorist attack requires rapid transport, appropriate triage, effective surgical approaches, and specific postoperative care. Disaster management can be effective in reducing mortality for injured patients. Recording the patients’ data is very diffi- cult in such situations. Performing triage is very effective in a disaster, but re-evaluation of the patients must not be forgotten. Lack of a prehospital healthcare system is an important reason for increased mor- tality. We suggest providing basic first aid training in schools, including teaching on simple triage principles. Appropriate triage algorithms for the public can be designed (green code: walking patient; yellow code: patient who is moving and asking for help; red code: unmoving/less mobile patient who is breathing; black code: nonbreathing patient).

Credit author statement

MED, IHA: Conceptualization, Methodology, Software; MED,IHA: Data curation, Writing- Original draft preparation; MB,MED: Visualiza- tion, Investigation; MB: Supervision; MB: Validation, Formal analysis; MB,MED: Writing- Reviewing and Editing; MED: Project administration;

None: Funding acquisition, Resources (no financial support for the research).

Funding

The authors received no financial support for the research, author- ship, and/or publication of this article.

Availability of data and materials

Submitted work is original and has not been published elsewhere in any language. Raw data are available for the editor on request.

Informed consent

Retrospective study.

Ethical approval and consent to participate

Ethics committee approval was obtained from Ethic board of Mogadishu Somalia-Turkey Recep Tayyip Erdogan Education and Re- search Hospital (Date: 25/12/2017; Decision no: 27/MSTH/4123). Con- sent to participate is not applicable for this retrospective study.

Human rights

Authors declare that human rights were respected according to the Declaration of Helsinki.

Consent for publication

Consent for publication was obtained from administration of Mogadishu Somalia-Turkey Recep Tayyip Erdogan Education and Re- search Hospital.

Declaration of Competing Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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