A Ballistic Missile Injuries in the Siege of Sarajevo 1992–1995

A

Ballistic Missile Injuries in the Siege of Sarajevo 1992–1995

John P. Beavis

569

To describe ballistic missile wounds without considering the environment in which they occur is incomplete and fallacious. The physics of ballistic missile injuries do not vary with geography, but the biological consequences for each victim will vary depending on the circumstances in which the injury occurs and the availability of treatment resources. The effects of war are multiple and it is impossible to separate the physical, and indeed the psychological, trauma caused by the overall environmental problems (Figure A-1).

Sarajevo was subjected to the longest siege in modern history, lasting from April 1992 until the latter part of 1995. Most of the casualties were sustained within the first two years, but there was a continuous war of attri- tion that left the medical facilities severely depleted and the hospitals badly damaged (Figure A-2).

The close proximity of the attacking units to the besieged citizens meant that civilian casualities outnumbered the military casualties (Figure A-3).

As in previous wars, the majority of surviving injured suffered wounds to their limbs (Figure A-4). In Sarajevo, sniper-fire wounds outnumbered those from mortar or shells by a ratio of two to one.

For much of the winter, the roads were impassable and re-supply was entirely dependent on an airlift that was subjected to vagaries of the climate.

This led to gradual starvation of the citizens, and effects on various vulner- able groups—infants, lactating and pregnant women, and the elderly—soon became apparent.

There is no doubt that severely wounded individuals representing 93% of the hospital population were also particularly at risk from malnutrition.

It is worth recording the reasons that wounded patients are so suscepti- ble to the effects of malnutrition and to relate it to special circumstances of Sarajevo.

1. Poor supply of essential nutrients to hospital and the rest of the city.

2. Increased requirement for protein, carbohydrates, and micronutrients

because of obligatory catabolic response to trauma and surgery.

Trauma

Effects of War

Heating, Transport, Medicines

Break Down of Civic Life, Education, Law and Order, Commerce, Health Services

Figure A-1. Effects of war.

Figure A-2. Sarajevo State Hospital.

Figure A-3. Ratio of civilian to military casualties.

3. During the winter there is an increased requirement for endogenous heat production because of inadequate heating of the wards—five- percent increase for every ten-degree drop in temperature. The ambient temperature in Sarajevo can often fall to minus fifteen degrees in winter.

4. Increased demand for nutrition for wound healing and infection—ten percent rise in calorie requirement for each one-degree rise in body tem- perature. (There is the paradox that the cause and effects are reciprocal, that is, poor nutrition causes infection and wound dehiscence).

5. In war, the majority of wounds are extensive and polytrauma is common.

6. The poor circumstances of the patients caused anorexia and depression, leading to refusal of food.

7. Poor quality food was presented because of the limited recipes and the lack of fuel for cooking. It was unpalatable and frequently rejected.

In the winter of 1993 to 1994, a survey was undertaken of the dietary status of hospital patients.

It was possible to demonstrate that not only was the dietary status of hospital patients inadequate, but there was a signifi- cant increase in pin track infection when reviewing individuals whose frac- tures had been treated with an external fixator (State Hospital Sarajevo, unpublished data, 1992–1994) (Figure A-5).

The city suffered from continued bombardment and, effectively, all within its confines can be considered as combatants. Despite the overall suscepti- bility of the Sarajevan civilians, the aid distribution as derived from a cohort study of war wounded indicated that young men were the most susceptible group (Figure A-6).

War injuries are inevitably substantial and more often than not result in multiple wounds requiring immediate resuscitation because of Grade 3 hemorrhage. During the war it was found that maintaining a relative hemodilution when compared with pre-war levels was entirely satisfactory.

The long-established methods of the management of war wounds were proved essential. This involved wide excision of related tissue and removal

WW2 ARAB/ISRAELI 1973 WW1

ARAB/

ISRAELI 1982

FALK

AFG 79–89

BOSNIA

Figure A-4. Percentage of limb injuries in previous wars.

of all foreign and dead material. Fasciotomy was considered imperative, along with external fixation of fractures and immediate repair of major arteries where necessary. Nerve injuries were never primarily repaired.

The initial onslaught on the city was so great that within days external and internal fixation devices were exhausted and no more were forthcom- ing. This led to the development of the external fixator known as Sarafix.

Just under 4000 patients were treated with this apparatus, with results that indicate that, even in extreme conditions, development of such a device is possible and allows adequate treatment of complex fractures (Figure A-7a).

A full study of the use of this device will never be possible because of the population drift that occurred in association with evacuation of seri- ously ill individuals, but a cohort review of 300 patients who remained

0%

20%

40%

60%

80%

100%

Aug'93 Nov'93 Jan'94

BLOCKADE

INFECTION RATE

%REQUIRED FOOD

0 % 5 % 1 0 % 1 5 % 2 0 % 2 5 % 3 0 %

< 1 6 y r s

1 6 - 1 9 y r s

2 0 - 2 9 y r s

3 0 - 3 9 y r s

4 0 - 4 9 y r s

5 0 - 5 9 y r s

> 6 0 y r s

Figure A-5. Relationship between reduction in available food for the wounded patients in the State Hospital Sarajevo and the pin track infection from August 1993 to January 1994.

Figure A-6. Demography of wounds on the basis of age throughout the war.

within the city showed that the complications of flexion deformities, pseudoarthrosis, osteomyelitis, and persistent pain occurred. The massive soft tissue injuries accounted for most of these complications (Figure A-7b).

The limited resources available led to the adaptation of surgical tech- niques with penetrating abdominal wounds. In particular, because of the lack of colostomy bags, primary suture of colonic injuries was undertaken.

A retrospective study of this work indicated that while solitary colonic injuries could be satisfactorily treated in this way, both multiple colonic injuries and multiple intra-abdominal injuries with peritoneal soiling (and persistent shock) were associated with breakdown of the anastomosis (State Hospital Sarajevo, unpublished data, 1992–1994). Therefore defunc- tioning colostomy is recommended under circumstances other than solitary colonic injury (Fig A-8).

The long-term consequences of ballistic missiles wounds on both the indi- vidual and their society are often overlooked. In a small study undertaken

Full Union Bridge +Defect Amputation Non union Mal Union Died

6%

3 5

3

82%

Figure A-7. (A) An example of a complex fracture treated with Sarafix. (B) Per- centage complications in 300 patients.

A

B

in Sarajevo involving 48 patients, persistent abnormality of gait and pain was recorded and over 50% of individuals had failed to return back to work because of the injuries sustained during the war.

Summary of Advice and Lessons Learned from Sarajevo Siege

The devastating effect of war should not just be analyzed in terms of the specific injuries that occur. The war-wounded patient must subsequently compete in a society which has itself been wounded in such a way that employment is reduced and the way of life remains adverse long after the missiles have ceased to fly. Unfortunately, after the initial flurry of interest, these societies and their wounded individuals are left to fare for themselves (Figure A-9).

Finally, a note of caution to all surgeons and anesthetists who seek to assist their hard-pressed and overworked colleagues in war zones. The normal peacetime standards of surgery must be aimed for and clinicians must be prepared to work in an environment that is not only hostile, but one in which adaptation to a lack of resources is essential. Transporting spe- cialists’ elective skills such as arthroscopy to a war zone will seldom, if ever, be useful, and a strong background in general traumatic surgery is essen- tial. All volunteers should be trained to the Advanced Trauma Life Support (ATLS) standard for resuscitation and immediate care. In an attempt to

* Solitary injury - Resected or Sutured - no colostomy (11) -1 leak (0.99%)

* Multiple injuries - Resected - no colostomy (55) - 6 leaks (10.9%)

* Multiple injuries - Resected with colostomy (30) -2 leaks (6.6%)

Figure A-8. Study of immediate colon repair in 394 penetrating abdominal wounds.

0 5 10 15 20 25

34% pre-war work

6% limited work

50% unemployed due to injury

Figure A-9. Pre- and post-war working pattern in injured Sarajevo patients.

counteract the effects of early specialization, the International Committee of the Red Cross organizes excellent surgical courses that will, in many ways, compensate for the limited spectrum of skills and help volunteers to appreciate the problems that they will encounter. A besieged city, or any other war zone, is no place for medical tourists.

It is recommended that those medical professionals who are interested in treating war wounds in conflict zones should consider it their obligation to maintain an interest in post-war reconstructive surgery, education, and continued persuasion of politicians and industrialists to assist the recovery of the damaged society. In this way, those who have been severely injured and have persistent disability will be best assisted towards a reasonable way of life.

References

1. Beavis JP. Hunterian lecture. London: Royal College of Surgeons. December 16, 2003.

2. Djozic S. A Study of a Cohort of Severe Limb Injuries from High energy Missile Wounds [master’s thesis]. Sarajevo: University of Sarajevo; 2002.

3. Vespa J, Watson F. Who is nutritionally vulnerable in Bosnia—Herzegovina?

BMJ. 1995;311:652–654.

4. Beavis JP, Harper S. Hospital patients in Bosnia are nutritionally vulnerable.

BMJ. 1996;312:315.

A. Ballistic Missile Injuries in the Siege of Sarajevo 1992–1995 575