I wish I had ready, searchable access to World War II or Vietnam era surgical journals to see if anything similar to this was published during a time of major conflict. An article entitled "Surgical Lessons Learned from Suicide Bombing Attacks," from the Department of Surgery and Trauma Unit, Hadassah University Hospital, Jerusalem, Israel, was published in this month's Journal of the American College of Surgeons (subscription required, but abstract accessible).
Several changes that occurred over the past 2 decades have made the explosive devices more lethal in Israel. The explosive material, which used to be composed of homemade, low-grade material, has been replaced by high-grade military material. The shift to high-grade material has enabled the attackers to add a large amount of heavy shrapnel to the bomb, intensifying the effects of penetrating trauma. Detonation through delayed timers or remote-control has been replaced by precise timing by the attacker. A final change is the location and position of the explosive device. The explosive device, which was once concealed under seats and inside garbage bins, is now carried at chest height, and detonated in the center of a crowd. These changes have brought about a marked increase in the number of fatalities per attack and the severity of injuries. For example, the number of fatalities per attack after bombings aboard buses in Israel has increased from a median of 3 in the 1980s to 9 in the 2000 to 2004 Intifada.It certainly gives one pause, as an American living in a free, open, and safe society, to understand that the Israelis have dealt with suicide bombings long enough to have their national trauma registry reflect that fact. As a trauma surgeon, I fear the day is coming when we may need just this type of information.
Primary blast injury is caused by the rapid outward spread of the shock wave. Injury to gas-containing organs, such as perforation of the middle ear and blast lung injury (BLI) are most common (22.1% and 18.2% of victims, respectively). Of all patients with BLI, 82% of victims aboard buses and in semiconfined spaces will suffer from moderate and severe forms of BLI compared with 33% of victims in open spaces. S econdary blast injury is caused by penetrating missiles that are propelled by the blast wave. More than 85% of victims of suicide bombing attacks (SBA) suffer from penetrating shrapnel and debris, most commonly to the head. Tertiary blast injury results from a patient’s body being displaced by expanding gases. Burns are termed quaternary blast injury and are also notably more common after explosions inside confined spaces compared with open spaces (33.9% versus 5% of victims, respectively). The hallmark of injuries after an SBA is the combination of blunt injury, multiple penetrating injuries with extensive soft tissue damage, and burns. Half of all patients hospitalized will be seen in a trauma unit setting and the same proportion will be admitted to an intensive care unit. Victims of SBAs are more severely injured compared with other trauma victims. Typical injuries include penetrating injury to the head (55%), extremities (49%), and torso (40%), burns (27%), open fractures (22%), and BLI (18%).