ObjectivesThe aim of this study was to explore possible long-term negative health effects of injuries sustained by modern weaponry.SettingThe study was conducted in Gaza’s main hospital, Al-Shifa ...Hospital.ParticipantsDuring the last 10 to 15 years, thousands of civilian Palestinians in Gaza have survived numerous military incursions, but with war-related traumatic injuries caused by explosive weapons. It is unclear to which extent the injuries sustained by such modern weaponry may increase survivors’ risks of negative long-term health effects and serious illness. We have reported mechanisms and severity of injury, demographics and psychosocial status among 254 Palestinian patients in Gaza with war-related extremity amputations. Among the same amputees, subgroups of patients presented a variety of alarming symptoms and findings. 94 patients received further diagnostic clinical exploration, radiology imaging and clinical chemistry laboratory tests at the main clinical centre in Gaza, the Al-Shifa Hospital.ResultsNine out of ten of the referred patients were young (median 31.5 years) males (88/94, 92.6%). Ultrasound imaging revealed that 19 of 90 patients (20%) had fatty liver infiltration, 3 patients had lung nodules and 10 patients had lung atelectasis on chest CT. Twelve had remaining shrapnel(s) in the chest, five patients had shrapnel(s) in the abdomen and one in the scrotum. We found shrapnel(s) in the amputation stumps of 26 patient’s amputated limbs, while 8 patients had shrapnel in the non-amputated limb. Three patients had liver lesions. Nineteen patients had elevated liver enzymes, 32 patients had elevated erythrocyte sedimentation rate and 12 were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (HBV). One of the 19 patients with fatty liver tested positive for HBV. Two of the patients with fatty liver infiltration had elevated glycatedhaemoglobin levels and confirmed diabetes mellitus type II.ConclusionNearly half (44, 8%) had remaining metal fragments from explosives of unknown composition harboured in various parts of their bodies. All patients identified with lesions and nodules are being followed up locally. As of now, we cannot anticipate the long-term health consequences of living with metal residuals from modern explosive weapons embedded in body organs and tissue.
More than 17.000 Palestinians were injured during different Israeli military incursions on the Gaza Strip from 2006 to 2014. Many suffered traumatic extremity amputations. We describe the injuries, ...complications, living conditions and health among a selection of traumatic amputees in the Gaza Strip.
We included 254 civilian Palestinians who had survived, but lost one or more limb(s) during military incursions from 2006 to 2016. All patients were receiving follow-up treatment at a physical rehabilitation center in Gaza at the time of inclusion. We measured and photographed anatomical location and length of extremity amputations and interviewed the amputees using standard questionnaires on self-reported health, socioeconomic status, mechanism of injury, physical status and medical history.
The amputees were young (median age 25,6 years at the time of trauma), well educated (37% above graduate level), males (92%), but also 43 children (17% ≤ 18 years). The greater part suffered major amputations (85% above wrist or ankle). Limb losses were unilateral (35% above-, 29·5% below knee), and bilateral (17%) lower extremity amputations. Pain was the most frequent long-term complaint (in joints; 34%, back; 33% or phantom pain; 40·6%). Sixty-three percent of amputees were their family's sole breadwinner, 75·2% were unemployed and 46% had lost their home. Only one in ten (11·6%) of the destroyed homes had been rebuilt.
The most frequently observed amputees in our study were young, well-educated male breadwinners and almost one in five were children. Conflict-related traumatic amputations have wide-ranging, serious consequences for the amputees and their families.
Little data exist to describe the use and medical consequences of drone strikes on civilian populations in war and conflict zones. Gaza is a landstrip within the Palestinian territories and the home ...of 2 million people. The median age in Gaza is 17·2 years and almost half of the population is below the age of 14 years. We studied the prevalence and severity of extremity amputation injuries caused by drone strikes compared with those caused by other explosive weapons among patients with amputations attending the main physical prosthesis and rehabilitation centre in Gaza.
In this retrospective cross-sectional study, we recruited patients from the Artificial Limb and Polio Centre (ALPC) in Gaza city in the Gaza strip with conflict-related traumatic extremity amputations. Patients were eligible if they had one or more amputations sustained during a military incursion in Gaza during 2006–16 and had an available patient record. Each patient completed a self-reporting questionnaire of the time and mechanism of injury, subsequent surgeries, comorbidities, and their socioeconomic status, and we collected each patient's medical history, recorded the anatomical location of their amputation or amputations, and interviewed each patient to obtain a detailed description of the incursion or incursions that led to their amputation injury. We classified the severity of amputations and number of subsequent surgeries on ordinal scales and then we determined the associations between these outcomes and the mechanism of explosive weapon delivery (drone strike vs other) using ordinal logistical regression.
We collected data on 254 patients from APLC who had sustained an amputation injury. Of these patients, 234 (92%) were male and 43 (17%) were aged 18 years or younger at the time of injury. The age of participants was representative of the Gaza population, with a median age at inclusion was 28 years (IQR 23–33), and the median age at the time of injury was 23 years (IQR 20–29). 136 (54%) amputation injuries were caused by explosive weapons delivered by drone strikes, with explosives delivered by tanks being the next most common source of amputation injury (28 11%). Adjusted for age and sex, drone-delivered weapons caused significantly more severe injuries than explosives delivered by other mechanisms (eg, military jet airplanes, helicopters, tank shelling, and naval artillery; odds ratio OR 2·50, 95% CI 1·52–4·11; p=0·0003). Compared with all other types of weapons, the patients whose injuries were caused by drone strikes needed significantly more subsequent surgical operations to treat their amputation injuries than those injured by other weapons (OR 1·93, 1·19–3·14; p=0·008).
Drone strikes were the most commonly reported cause of amputation injury in our study population and were associated with more severe injuries and more additional surgeries than injuries caused by other explosive weapons. Limitations of our study include the self-reported nature of the mechanism of injury and number of subsequent surgeries and selection bias from not incorporating amputation injuries from individuals who died immediately or due to complications. The increasing use of drones needs to be addressed, rather than passively accepted, by the international community. This study fills a gap in our knowledge of the civilian consequences of modern warfare and we believe it is also relevant to the growing populations that are being exposed to drone warfare and for health-care personnel treating these people.
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In the past 10–15 years, thousands of civilians in Gaza have experienced conflict-related traumatic injuries. How injuries affect survivors’ risks of negative long-term health effects and serious ...illness is unclear. We report follow-up findings in a group of patients with traumatic amputations.
Eligible patients had traumatically amputated limbs and showed signs and symptoms of possible serious illness on standardised clinical examination. The patients were all receiving rehabilitation treatment at the Artificial Limbs and Polio Centre, Gaza, which is the main provider of rehabilitation and protheses. All patients had suffered from at least one amputation during Israeli military incursions between 2006 and 2016. All were offered referral to the Al-Shifa Hospital, Gaza, for further diagnostic clinical, radiological, and laboratory tests. Each patient was examined by CT of the abdomen (or ultrasonography if CT could not be performed) and chest and MRI of the amputation stump or stumps. Laboratory analyses included ESR, complete blood count, kidney and liver function tests, serum glucose, creatine kinase, lactate dehydrogenase, and hepatitis B and hepatitis C virus infections.
Of 254 traumatically amputated patients assessed, 105 had signs and symptoms of possible serious illness, among whom 94 accepted referrals. 88 (93%) of 94 were men and the median age was 31.5 years, mean age 34 years (SD 9·6). Of 90 patients who had imaging, 19 (21%) patients had fatty liver infiltration, three (<1%) had lung nodules, and ten had lung atelectasis. Shrapnel was found in the chest of 12 patients (13%), the abdomen of five patients (6%), the scrotum of one patient (<1%), in the amputation stumps of 26 patients (29%), and the non-amputated limbs of eight patients (1%). Three (<1%) of 90 patients had liver lesions. 32 (34%) of 94 patients had elevated ESR, 19 (20%) had elevated liver enzyme concentrations, and 12 (13%) were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (one with fatty liver changes). Two of the 19 patients with fatty liver infiltration were diagnosed as having type 2 diabetes. A limitation of this study is that, owing to conflict-related supply-chain issues in Gaza, we were unable to collect complete data in four (5%) of patients.
As well as residual shrapnel in more than half of patients, a notable proportion of patients had fatty liver infiltration, for which we have no clear hypothesis. We recommend close medical follow-up for trauma patients in injured by explosives.
The Norwegian street-artist AFK provided €1,500 to this project, which was used to cover patients’ transportation costs.
During four separate Israeli military attacks on Gaza (2006, 2009, 2012, and 2014), about 4000 Palestinians were killed and more than 17 000 injured (412 killed and 1264 injured in 2006; 1383 killed ...and more than 5300 injured in 2009; 130 killed and 1399 injured in 2012; and 2251 killed and 11 231 injured in 2014). An unknown number of people had traumatic amputations of one or more extremities. Use of unmanned Israeli drones for surveillance and armed attacks on Gaza was evident, but exact figures on numbers of drone strikes on Gaza are not available. The aim of this study was to explore the medical consequences of strikes on Gaza with different weapons, including drones.
We studied a cohort of civilians in the Gaza Strip who had one of more traumatic limb amputation during the Israeli military attacks between 2006 and 2016. The study was done at The Artificial Limb and Polio Center (ALPC) in the Gaza Strip where most patients are treated and trained after amputation. We used standardised forms and validated instruments to record date and mechanism of injury, self-assessed health, socioeconomic status, anatomical location and length of amputation, comorbidity, and the results of a detailed clinical examination.
The studied cohort consisted of 254 Paletinian civilians (234 92% men, 20 8% women, and 43 17% children aged 18 years and younger) with traumatic amputations caused by different weapons. 216 (85%) people had amputations proximal to wrist or ankle, 131 (52%) patients had more than one major amputation or an amputation above the knee, or both, and 136 (54%) people were injured in attacks with Israeli drones, including eight (40%) of the women. The most severe amputations were caused by drone attacks (p=0·0001). Extremity injuries after drone attacks led to immediate amputation more often than with other weapons (p=0·014). Patients injured during cease-fire periods were younger than patients injured during periods of declared Israeli military operations (p=0·0001).
Weapons fired on the Gaza Strip from Israeli drones caused severe injuries in surviving Palestinian civilians. Drone-fired missiles resulted in major amputations in almost all victims who had limb losses. Substantially more severe injuries were inflicted by the drone-launched explosives than by other weapons used during the Gaza War. Traumatic amputations caused by drones were often immediately complete. One limitation of our study is that it does not elucidate injury patterns in victims with fatal injuries.
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During four separate Israeli military attacks on the Gaza Strip (in 2006, 2009, 2012, and 2014), about 4000 Palestinians were killed and more than 17 000 Palestinians were injured (412 killed and ...1264 injured in 2006; 1383 killed and more than 5300 injured in 2009; 130 killed and 1399 injured in 2012; and 2251 killed and 11 231 injured in 2014). An unknown number of people had traumatic amputation of one or more extremities. In addition to loss of body parts, loss of work and income further complicated patients' lives after trauma. In 2015, we reported preliminary data on the somatic consequences, showing that eight of ten amputees had unilateral or bilateral lower limb amputations, most often because of attacks by drone-carried weapons. A third of cases had amputations during ceasefire periods. A high number of debilitating extremity injuries were in the young civilian population, where needs of rehabilitation were difficult to meet because of limited local resources during the long-lasting siege of the Gaza Strip. Here we report long-term functional and psychosocial consequences of traumatic amputations in Gaza War casualties.
This cross-sectional study was done at The Artificial Limb and Polio Center, a local rehabilitation centre in Gaza City. We studied Palestinians living in the Gaza Strip who had sustained traumatic amputations during Israeli military attacks between 2006 and 2014. We explored the amputees' self-assessed health, socioeconomic status, anatomical location and level of amputation, comorbidity, and date and mechanism of injury. We used two validated and self-administered screening questionnaires (36-Item Short Form Survey and General Health Questionnaire 12 GHQ12) combined with a detailed clinical examination of each amputee. We used standardised records and questionnaires in Arabic. Data were analysed with SPSS. The study was approved by the Palestinian Ministry of Health in the Gaza Strip, Al-Shifa Hospital's board, and the director of the Artificial Limb and Polio Center in the Gaza Strip. All participants included in the study completed a written consent form.
We included 165 Palestinians in this study. Pain was reported by more patients who were unable to continue work because of the traumatic amputation than by patients who were unemployed for other reasons, even when adjusting for time passed since amputation (p=0·039). We found a correlation between reported pain and poverty (income <800 shekels per month; χ2=0·034) but no correlation between GHQ12 scores indicating psychological distress and the extent of the initial trauma. Use of prosthetics decreased GHQ12 scores, suggesting a lower level of psychological distress in users of artificial limbs.
Self-reported pain after loss of one or more limbs correlated with deteriorated occupational and financial life situation after the amputation. Use of prosthesis seemed to ease the psychological distress. Poverty and unemployment caused by amputations and disability might be a more important trauma than the physical amputation itself.
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Four major attacks on Gaza since 2006 have killed around 4000 and injured more than 17 000 Palestinians. An unknown number of the wounded suffered extremity injuries with amputations. The long-term ...functional, somatic, and psychosocial consequences of traumatic amputations in Gaza have not been reported. We describe the demography, anatomical distribution, and causative factors of a sample of traumatic amputations in Gaza in this ongoing study.
We studied 147 randomly selected Palestinian surviving casualties in Gaza who had suffered traumatic amputations following Israeli military operations during the period 2006–2014. All participants were aged over of 16 years when included. One additional patient was invited to participate but declined. We organised the study at a key rehabilitation centre, the Artificial Limb and Polio Centre (ALPC) in Gaza City. Data were collected from June to October, 2014. We recorded date and mechanism of injury as well as results of in-depth clinical examinations in each survivor. Records and self-administrated questionnaires in Arabic were translated into English and data analysed with SPSS common version 21·0. The Palestinian Ministry of Health, the board and directors at Al-Shifa Hospital, and ALPC approved the protocol. We obtained written informed consent from each patient.
11 women (7·5 %) and 136 men (92·5 %) with traumatic amputations participated. The mean age was 30·6 years (range 16–64). 85 patients (57·8 %) had unilateral lower extremity amputations, 31 (21·1%) bilateral lower extremity amputations, and 31 (21·1%) other amputations. Attacks from drones were reported by the survivors as the reason for explosions that caused amputation injury in 85 of the cases (57·8%). 52 (61.2 %) of such drone attacks had occured during declared military operations. 24 (31·6 %) had occurred during periods of ceasefire. Nine (11·8%) participants reported only the month and year of attack, not the exact day.
Military operations in Gaza have caused a large, unknown number of traumatic amputations. In our study, most participants had unilateral or bilateral lower limb amputations and the majority of injuries followed attacks with drone-carried weapons. Several participants were wounded during ceasefire periods. The need for rehabilitation is difficult to meet because of limited local resources.
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ObjectivesThe aim of this study was to explore determinants of psychosocial distress and pain in patients who have survived severe extremity amputation in Gaza.SettingThis study was conducted in a ...secondary care rehabilitation centre in Gaza, Palestine. The clinic is Gaza’s sole provider of artificial limbs.ParticipantsWe included 254 civilian Palestinians who had survived but lost one or more limb(s) during military incursions from 2006 to 2016. We included patients with surgically treated amputation injuries who attended physical rehabilitation at a specialist prosthesis centre in Gaza. Amputees with injuries prior to 2006 or non-military related injuries were excluded.We assessed their pain and psychological stress using the General Health Questionnaire (GHQ-12). We used income, amputation severity scored by proximity to torso, current employment status, loss of family members and loss of home as independent variables.ResultsThe amputees median age was 23 years at the time of trauma, while a median of 4.3 years had passed from trauma to study inclusion. Nine of 10 were male, while 43 were children when they were amputated (17%≤18 years). One hundred and ninety-one (75%) were unemployed and 112 (44%) reported unemployment caused by being amputated. Pain was the most frequent problem, and 80 amputees (32%) reported to suffer from daily pain. Family income was significantly correlated with the physical pain (OR=0.54, CI 0.36 to 0.80, p=0.002). Psychological distress was higher among unemployed amputees (OR=1.36, CI 1.07 to 1.72, p=0.011). We found no association between psychological distress (GHQ-scores) and the extent of the initial amputation.ConclusionPain and psychological distress following war-related extremity amputation of one or more limbs correlated stronger with deteriorated family economy and being unemployed than with the anatomical and medical severity of extremity amputations.
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