Abstract Hypothermic cardiac arrest has high mortality and few known prognostic factors. We studied retrospectively 34 victims of accidental hypothermia with cardiac arrest admitted to The University ...Hospital of North Norway during 1985–2013 who were resuscitated and rewarmed by extracorporeal circulation. No patient survived prior to 1999, while nine out of 24 (37.5%) survived hypothermic cardiac arrest from 1999 to 2013. The lowest measured core temperature among survivors was 13.7 °C; the longest time from cardiac arrest to return of spontaneous circulation was 6 h and 52 min. The only predictor of survival identified was lower blood potassium concentration in the nine survivors compared with the non-survivors. Submersion was not associated with reduced survival. Non-survivors consumed modest hospital resources. Most survivors had a favourable neurological outcome.
Background The Israeli military attack Pillar of Defence on the Gaza Strip, occupied Palestinian territory (also referred to as State of Palestine), from Nov 14–21, 2012, killed more than 190 and ...injured more than 1490 Palestinians. 48 of the people killed were aged 18 years or younger, and 16 were 5 years or younger. 504 of the people injured were aged 18 years or younger, and 195 were 5 years or younger. The rest of the individuals injured or killed were older than 18 years. Six Israelis were killed and 224 were injured. We were working in Al-Shifa Hospital, Gaza City, during the attacks and assessed the flow of patients through the emergency department during 8 days of bombing by the Israeli military. Methods Data for all patients brought to Al-Shifa Hospital's emergency department were obtained retrospectively from handwritten emergency department protocols, and intensive care unit (ICU) and operating room records. We recorded the total number of hospital admissions, deaths, admissions to the ICU, patients operated on, and patients transferred to Egypt. Data were gathered for admissions, demographics, cause of injury, surgery, ICU admissions, and deaths. Microsoft Excel 2010 was used to analyse the data. The study was approved by the hospital's director and board. Findings 680 of the injured or killed Palestinians were brought to the hospital's emergency department with injuries from bombing by drones, F-16 fighter planes, helicopters, or naval artillery: 501 (74%) male and 179 (26%) female individuals, including 74 (11%) children aged 18 years or younger. 145 (21%) Palestinians were admitted: 44 (30%) during the first 4 days and 101 (70%) during the last 4 days of bombing. 43 (30%) of 145 individuals needed intensive care (32 74% adults and 11 26% aged ≤5 years). Of the patients admitted to the ICU, 29 (67%) were discharged, 11 (26%) transferred to Egypt, and three (7%) died in the ICU. 62 (9%) of 680 people who were injured died: 50 (81%) were dead on arrival, seven (11%) died in the operating room, three (5%) died in the ICU, and two (3%) after transfer to Egypt. 110 (76%) of 145 patients admitted to Al-Shifa Hospital were operated on, most were taken directly to the operating room after rapid triage and critical stabilisation in the emergency department. 39 (35%) patients had laparotomies, and 42 (38%) orthopaedic, 22 (20%) neurosurgical, eight (7%) vascular, and four (4%) plastic surgical operations; total number of operations was greater than 110 because most patients had more than one trauma. 39 patients were transferred to Egypt. Most of the people with injuries were civilians. Interpretation A large influx of patients who had war trauma was managed in Al-Shifa Hospital despite the erosion of infrastructure, supplies, and general population health from the previous 5-year Israeli siege. Improved, stricter triage reduced patient admission during the 2012 Israeli military attack versus the Israeli military attacks in 2008–09. Additionally, hospital staff were better prepared and trained for the casualties of the 2012 military attack and few deaths occurred in the ICU. A high number of individuals with fatal injuries were dead on arrival, indicating the need for better prehospital triage to safeguard hospital capacity. Funding None.
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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The atrocities in Syria have been covered in the four general medical weekly journals in the USA and the UK. Medical journal articles addressing political determinants of public health have rightly ...described and criticised the international community's failure to enforce humanitarian law while urging global bodies of power to ensure protection of civilians and civilian infrastructure and medical services. Discussions of the political influences on health of people in the occupied Palestinian territory (West Bank and Gaza Strip) seem to be considered politically out-of-bounds by some medical journals. This study used a keyword-based search to explore patterns of publication about the occupied Palestinian territory and Israel by four large US and European medical journals.
The four highest ranked, peer-reviewed, international medical journals were searched: The Journal of the American Medical Association (JAMA), The New England Journal of Medicine (NEJM), The Lancet, and The British Medical Journal (BMJ). Searches were conducted between Sept 1 and Sept 6, using each journal's search engine with the keywords “Gaza”, “West Bank” and the stems “Palestin*” and “Israel*” in all fields for the period Jan 1, 1990, to Sept 6, 2016. News and commentary articles were included in the findings.
The searches found the term “Palestin*” in 49 articles from the two US journals (32 in JAMA; 17 in NEJM) and 694 articles in the two UK journals (236 in The Lancet; 458 in BMJ). “Israel*” was found in 840 articles in US journals (386 in JAMA; 454 in NEJM) and in 2972 articles in UK journals (1388 in The Lancet; 1584 in BMJ). “West Bank” was found in nine articles in US journals (nine in JAMA; none in NEJM) and in 297 articles from the UK (211 in The Lancet; 86 in BMJ). “Gaza” was found in 18 articles in US journals (15 from JAMA; three from NEJM) and in 487 articles in UK journals (324 in The Lancet; 166 in BMJ).
Compared with the two US-based medical journals, the UK journals published substantially more articles with the relevant keywords and discussed political responsibilities for the dire health conditions experienced by the Palestinian people. The journals included in this study differed in the extent to which they featured news and comments, which might have affected the number of published articles. Because there is a larger research establishment in Israel than in the West Bank and the Gaza Strip, the keyword “Israel” might have been included in a larger number of clinical and biomedical scientific papers. Medical leaders, including journal editors, have a responsibility to participate in the discussion around this preventable situation, which could have long-lasting public health consequences.
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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.
Weekly protests at the Israeli-Gaza fence started on Land Day, which commemorates the 1976 killing of six unarmed Palestinians during protests against land expropriation in the Galilee.2 As ...documented in this report, the response to the Great March of Return protests have generated another source of humanitarian emergency in Gaza. Since the start of demonstrations, the number of casualties is staggering. 277 Palestinians have been killed—including 41 children—and 31 214 have been injured, 16 556 of whom required hospital transfer and treatment. Of those patients, 3310 were children.3 Limb injuries secondary to Israeli security forces high-velocity, close range weaponry fire condemn a new generation of Palestinians to life with disability in a population already suffering from high rates of extremity injuries and amputations from previous wars.4–6 Of the 6846 live ammunition casualties since 30 March, 5784 have involved the limbs.3 In April 2018, Medicins Sans Frontieres (MSF) noted the ‘devastating limb injuries of unusual severity, which are extremely complex to treat’.7 The numbers attest to this—128 patients have required amputations while at least 700 patients will require long-term limb reconstruction, requiring multiple surgeries and years of rehabilitiation.3 8 9 The complexity and volume of injuries, MSF noted recently, would ‘…overstretch the best healthcare systems in the world’.10 Israel has boasted of the intentionality to maim or kill behind every shot fired,11 which is in line with their policy of deliberately disabling youth in West Bank refugee camps.12 Complicating the ability to effectively care for casualties, and a key component of the report’s concerns for crimes against humanity committed against Palestinian protesters, has been the Israel security force’s targeting of health professionals. Approximately 1 hour later, the Palestinian first responder who treated the Canadian physician’s leg injuries was killed while providing care to another wounded patient near the fence.17 Despite UNHRC’s independent commission report noting that Israeli security forces violations may constitute crimes against humanity for targeting and killing Palestinian protesters posing no imminent threat of death or serious injury to others, including children, journalists, disabled people and health workers,1 attacks on Palestinians continue while the international community fails to develop a coherent or meaningful response to this use of deadly force.
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.
The Israeli Army military operations against Gaza from July 8 to Aug 26, 2014, left more 2100 Palestinians dead and injured over 11000. According to UN data, at least 551 of those killed and at least ...3436 were those injured were children aged 18 years or younger. We assessed patient flow, triage, and mortality at Al-Shifa Hospital in Gaza City (Shifa) during this period.
We reviewed hospital records for the emergency room, intensive care unit, and operating rooms in Shifa. Total numbers of casualties seen in the emergency room, admissions, deaths, operations, and ICU admissions were recorded.
8592 people came to the Shifa emergency department following bombardments and other attacks. After crude emergency room triage, 4389 (51·1%) needed further medical attention, while 490 (5·7 %) were dying or dead on arrival. 1808 (21·0 %) live patients were admitted after detailed triage, of whom 78 (4·3 %) died in hospital. Most patients were civilians injured by aerial bombing (drones, F-16 jets, helicopters) or heavy ground or naval artillery shelling. 842 (46·6 %) admitted patients needed major life-saving surgery with anaesthesia, including 190 laparotomies, 146 orthopaedic fixations, 106 craniotomies, 69 thoracotomies/airway interventions, 38 vascular procedures, 49 amputations, 68 debridements, and 176 other procedures. Because most patients needed more than one intervention, the total number of procedures exceeded 842. The surgical intensive care unit treated 253 patients, including 197 (77·9 %) male and 56 (22·1 %) female patients. 87 (34·4 %) of cases were children. 164 (64·8 %) patients were discharged alive, 51 (20·2 %) died in intensive care, and 38 (15%) were transferred to other hospitals.
A high proportion of fatal injuries presented dead on arrival at hospital. The rate of admission to ICU doubled and ICU mortality rates nearly tripled compared with those during the the Israeli operation Pillar of Defence in November, 2012, probably because of the extreme character of the 2014 attacks, combined with shortages of supplies and hampered evacuation caused by siege. Despite severe shortages of medical staff and unpaid salaries, Shifa staff and volunteers managed the long-lasting influx of patients with serious trauma.
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