Downloaded from http://jramc.bmj.com/ on September 27, 2017 - Published by group.bmj.com

Case report

Home-made explosive found inside injured Afghan Steven Pengelly,1 N Moore,2 D Burgess,3 M Mahlon,4 T Rowlands,5 T Cubison6 1

Department of Surgery, MDHU Derriford, Derriford Hospital, Plymouth, UK 2 Nuffield Department of Medicine, University of Oxford, Oxford, UK 3 Department of EOD and Search Squadron, Royal Logistics Corps, Task Force Helmand, Afghanistan 4 Department of Radiology, Role 3 Medical Treatment Facility, Camp Bastion, Afghanistan 5 Department of Orthopaedic and Trauma Surgery, RCDM, Birmingham, UK 6 Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, UK Correspondence to Surg Lt Cdr Steven Pengelly, Department of Surgery, MDHU Derriford, Derriford Hospital, Plymouth PL6 8DH, UK; [email protected] Received 11 March 2014 Revised 18 May 2014 Accepted 21 May 2014 Published Online First 26 June 2014

ABSTRACT There is extensive literature on metal fragments from improvised explosive devices being embedded in patients but there are no reports describing the clinical and radiological appearances of embedded home-made explosive (HME). We present a case of partially detonated HME being found inside a patient’s forearm. We discuss the medical management of the injury, the ongoing risk to the patient and surgical team associated with the explosive and the safe disposal of the substance.

INTRODUCTION There are many reports in the literature of metal fragments from improvised explosive devices (IEDs) being found in patients and a review article concerning the removal of unexploded rounds where the risk was already known about prior to the operation.1 These were mostly 40 mm grenade launcher rounds from the Vietnam War and this article recommended removing the ordnance in a sandbagged area away from main theatres and then, once removed, taking the patient to theatres for their definitive procedure. In all, 36 patients were identified, with no cases of the round subsequently exploding and causing further injury. Reports were also found concerning the removal of white phosphorus. This is another substance found in military surgery that can pose a risk to the operating team; it oxidises in air causing further damage to surroundings and requires special arrangements for its removal.2 We could not find any reports advising on the unexpected find of the uncontained explosive material itself.

CASE REPORT

To cite: Pengelly S, Moore N, Burgess D, et al. J R Army Med Corps 2015;161:150–152. 150

A 22-year-old Afghan male patient presented following a dismounted IED blast with injuries to both his legs and his left arm. He had sustained a traumatic right below-knee amputation with a distal femoral fracture, and soft tissue injury to the left leg. His left upper limb had sustained soft tissue loss to the ring and little fingers, the ulnar aspect of his forearm, and a further wound in his upper arm. He underwent resuscitation in the Emergency Department before undergoing CT. CT traumagram showed comminuted ulnar diaphyseal and styloid process fractures with fractures of the ring finger and middle fingers, amputation of the distal phalanx of the ring finger, and radio-opaque foreign material impacted in the forearm (Figure 1). Stones, grit and soil are commonly seen on CT after blast injury and so it was assumed that this was the explanation of the radio-opaque foreign bodies.

Operative management The patient was taken to the operating theatre and debridement of his legs and left arm was commenced using a multi-surgeon approach. On debridement, extensive necrotic muscle between the radius and ulna was found deep to less damaged tissue, giving the appearance of having been burned from the inside out (Figure 2). A similar appearance was found in the hand. In the deeper burned areas of the forearm, two golf ballsized lumps of a grey-green speckled substance with the consistency of toothpaste were found and removed. Concern was raised that this was likely to be home-made explosive (HME). The Regimental Sergeant Major and the Hospital Operations room were informed and the substance was removed in a metal box to the hospital unexploded ordnance (UXO) pit by personnel wearing appropriate personal protective equipment (PPE). As the operation progressed, it became clear that the soft tissue injury was incompatible with reconstruction and so amputation was performed through the ulnar fracture site. Once the risk of explosive material was raised, steps were taken to reduce the risk of detonation. These included stopping diathermy and other power tools, and covering the surgical field in adrenaline-soaked swabs to minimise blood loss. After confirmation of the presence of potassium chlorate HME, the surgical team were advised to minimise use of electrical equipment and use a bipolar diathermy source only as this produces lower temperatures at the tip than monopolar diathermy.3 A tourniquet was already in place; therefore, there was no immediate issue with bleeding and the amputation at mid-forearm was performed with a hand saw. The radial skin was raised with the radial artery to provide eventual stump cover and the forearm dressed with adrenaline soaked gauze and topical negative pressure. The patient was discharged to Kabul Hospital 3 days later.

Management of explosive The Explosive Ordnance Disposal (EOD) team was contacted and, while waiting for its arrival, the ‘4 Cs’ of Confirm, Clear, Cordon and Control, the universal approach to dealing with explosives found anywhere, were carried out around the HME as this was where the greatest risk lay. There did not appear to be any remaining explosive within the patient; however, theatres were cleared of non-essential personnel and those who needed to remain wore PPE (ballistic eye protection). The theatre was then cordoned off and entry controlled. A formal cordon was placed around the hospital UXO pit until the explosives team removed the substance.

Pengelly S, et al. J R Army Med Corps 2015;161:150–152. doi:10.1136/jramc-2014-000270

Downloaded from http://jramc.bmj.com/ on September 27, 2017 - Published by group.bmj.com

Case report

Figure 1 Ulna fracture with radio-opaque material.

Figure 2

Damaged deep hand and forearm tissue.

DISCUSSION Explosives in the operating theatre pose a risk to patients and theatre staff, and other hospital staff and patients in the surrounding area. It is very common to find foreign material in patients after blast injury. Metal fragments and pieces of bone are easily seen on plain X-ray and in Afghanistan soil, grit and stones are also seen on X-ray and CT. The CT images of the patient were reviewed retrospectively. Two different substances, soil and the HME, were seen inside the forearm: the HME was compressed against the radius (Figure 3) and had a density less than that of the soil (1309 vs 2043 Hounsfield Units), which was not compressed. The substance was confirmed to be potassium chlorate and the total volume was calculated to be 15 cm3. This would have given a blast radius of 3–5 m, had it been dry and compacted. The HME was not likely to combust spontaneously and requires detonation to explode. The EOD officer has subsequently advised that as the substance was wet, non-confined and would have already begun to leach away, there was minimal risk of detonation by diathermy and that, if kept wet, the substance was safe to remove in an open metal container, rather than having to evacuate theatre. This was not known at the time and so it was safer to assume a risk of detonation until the substance was removed, or until confirmed that there was no risk. Once the HME had been removed, there was no risk of explosion but

we were advised diathermy still carried a risk of producing toxic fumes from HME that had leached into the tissues. Suction was used to minimise this risk along with use of bipolar diathermy instead of monopolar as this produces a lower temperature.3 Potassium chlorate is known to cause irritation to the respiratory tract, to be an irritant to skin and to be toxic in ingestion, but is not known to produce significant chemical burns when exposed

Figure 3 Radio-opaque material compressed against and conforming to the shape of the radius.

Pengelly S, et al. J R Army Med Corps 2015;161:150–152. doi:10.1136/jramc-2014-000270

151

Downloaded from http://jramc.bmj.com/ on September 27, 2017 - Published by group.bmj.com

Case report to open wounds.4 It is thus thought that the deep tissue damage was thermal and not chemical in nature. The nuclear, biological and chemical threat is trained for and hospitals are equipped to manage this risk where the situation arises. Medical staff wear PPE routinely to protect against biological hazard injury caused by sharp objects but are less used to dealing with explosives and as this situation is so unusual it may not be obvious how to continue. The 4Cs are the actions on finding a suspected IED. In the light of this experience, we would suggest that these could be interpreted as: Confirm ▸ Be aware of the possibility of finding explosive in a patient, particularly if there are signs of heat injury to the deep tissues ▸ Report the case up the chain of command who in turn will call EOD Clear ▸ All non-essential personnel should be cleared from the vicinity of the suspected explosive. It is recognised that a surgeon and an anaesthetist are likely to have to stay for management of airway, breathing and haemorrhage control ▸ Cleared personnel should retrieve the PPE of the anaesthetist and surgeon who should don it where practicable ▸ If possible, remove the suspicious substance in a suitable container to the hospital UXO pit Cordon ▸ Set up a cordon around the theatre area/UXO pit with staff on cordon positions wearing PPE. Appoint a cordon 2IC to ensure integrity Control ▸ Check the integrity of the cordon ▸ Set up an incident control point, likely to be the Hospital Reception, to control access and report to EOD when they arrive

152

CONCLUSIONS Military surgeons need to be aware of the potential risks to themselves while working in an operational environment. In this case, the risk was from ordnance; in other conflicts, the risk may be chemical, biological or from radiation. However, unexpectedly coming across a risk such as the one described in this article presents a challenge for managing safely and quickly. By adherence to the principles of the 4Cs, it is possible to maintain safe practice while finishing the operation. Contributors TC conceived of the article. SP, TC and TR operated on the patient and looked after him on the ward. NM and MM interpreted the imaging. SP wrote the article with assistance of all the authors. All authors approved the final draft. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES 1 2 3

4

Lein B, Holcomb J, Brill S, et al. Removal of unexploded ordnance from patients: a 50-year military experience and current recommendations. Mil Med 1999;164:163–5. Chou TD, Lee TW, Chen SL, et al. The management of white phosphorus burns. Burns 2001;27:492–7. Sutton PA, Awad S, Perkins AC, et al. Comparison of lateral thermal spread using monopolar and bipolar diathermy, the Harmonic Scalpel™ and the Ligasure™. BJS 2010;97:428–33. National Library of Medicine Toxicology Data Network. http://toxnet.nlm.nih.gov/ cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+1110 (accessed 5 Apr 2014)

Pengelly S, et al. J R Army Med Corps 2015;161:150–152. doi:10.1136/jramc-2014-000270

Downloaded from http://jramc.bmj.com/ on September 27, 2017 - Published by group.bmj.com

Home-made explosive found inside injured Afghan Steven Pengelly, N Moore, D Burgess, M Mahlon, T Rowlands and T Cubison J R Army Med Corps 2015 161: 150-152 originally published online June 26, 2014

doi: 10.1136/jramc-2014-000270 Updated information and services can be found at: http://jramc.bmj.com/content/161/2/150

These include:

References Email alerting service

This article cites 3 articles, 0 of which you can access for free at: http://jramc.bmj.com/content/161/2/150#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.

Notes

To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/

Home-made explosive found inside injured Afghan.

There is extensive literature on metal fragments from improvised explosive devices being embedded in patients but there are no reports describing the ...
533KB Sizes 2 Downloads 3 Views