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Monday, May 10, 1999 Published at 14:57 GMT 15:57 UK


Treating London's bomb victims

As the victims of Soho's nail bomb attack begin a slow recovery, Dr David Ross, one of the plastic surgeons involved in their treatment, tells BBC News Online about his demanding, often traumatic, work.

A nail bomb is an awful and inhumane device. It produces a number of effects that cause dramatic, life-threatening injuries. The blast sends heavy, sharp, metal objects ripping through soft tissues and bone.

The nail bomb terror
For those standing close to the nail bomb that exploded in the the Admiral Duncan pub in London's Soho district, this produced awful wounds, compounded by the effects of the blast itself.

The flash of the explosion caused extensive burns in several of the patients. Flash burns are usually superficial, but these wounds were deeper as, in some cases, clothes caught fire.

The blast itself produced significant bruising and sent shrapnel and debris flying into the victims.

Almost all the severely injured patients will, at some point, need care under plastic surgeons as they sustained major soft-tissue injuries.

Extensive injuries

My initial role was to examine and assess one of injured, known at that stage only as "patient 60", and prevent further blood loss.

The patient had sustained awful injuries to his left side, in particular to his leg and arm. His leg injury was so severe that the limb had to be amputated.

[ image: Some blast victims had extensive burns]
Some blast victims had extensive burns
This was an awful thing to have to do, but we were left with no choice as his limb was too damaged to survive and would have resulted in further blood loss and risk of death.

Patient 60 had also sustained blast injuries to both his arms and left flank from which shards of glass and metal were retrieved. Once the wounds had been identified, they were all thoroughly cleaned and explored. It was evident that our patient also had extensive burns to his left arm and side.

Three patients had suffered extensive, but relatively superficial burns. These patients required intensive care to replace lost tissue fluids, control pain, change dressings and begin mobilising (moving the damaged tissue to aid circulation, prevent seizure and ensure proper healing).

Fortunately, despite the extent of their injuries, these burns are unlikely to produce permanent scarring and would be expected to completely heal in two to four weeks.

Two other patients were still in the operating theatre with combined blast injuries and burns. Both required leg amputations, cleaning of their wounds and dressings.

In both cases these patients were very badly injured and needed observation in the intensive care unit. Unfortunately the following day, one of these patients died.

Splints and grafts

Patients with contaminated wounds need to return to theatre at least every 48 hours to undergo further cleaning, removal of non-viable tissues and redressing.

Once the wounds are clean enough they may be sutured, heal spontaneously or need covering every two to three hours.

[ image: Patients had to return to surgery several times]
Patients had to return to surgery several times
An initial priority was to ensure that any burned hands were splinted and, if necessary, skin grafted. This is because burned hands rapidly swell and develop joint contractures (in which the damaged area seizes up in a permanently flexed position). If the skin is deeply burned, function is permanently lost.

Accordingly it is essential to remove deeply burned tissue at an early stage and commence physiotherapy to the joints even with the patient still under sedation on the intensive care unit.

These procedures are lengthy and delicate as skin grafts have to be meticulously applied to ensure they take.

As our patients' general condition has improved we have been able to graft more extensive areas, including wounds on the arms and legs. Skin grafts are usually taken from the thigh.

However, in these patients we have been faced with the problem that many of these areas have also been burned and we may have to obtain skin from the abdomen or back. If this is not possible we will have to use cadaveric skin (from other dead donors) to provide temporary cover.

These patients will have to return to theatre six or eight times before they are well enough to have their dressings changed on the ward. As their burns heal, deeper wounds may need excision and skin grafting.

Road to recovery

In all, it may take six weeks before our patients have healed and the initial phase of their treatment is over. During this time careful attention will be paid to nutrition in order to sustain the repair process.

Recovery will be slow and painful and our patients will require considerable physiotherapy to mobilise stiff joints and limbs.

[ image: Physoitherapy is just one of the follow-up treatments needed]
Physoitherapy is just one of the follow-up treatments needed
Scars take up to two years to become pale and soften. During this time it may be necessary for patients to wear compression garments (a tight fitting, made to measure lycra garment worn to control the over production of raised red scarring after burns) to minimise thickening and deformity.

Almost all this care will be under the responsibility of plastic surgeons. For those patients who have lost legs, the recovery process will be much more difficult, slow and will involve the expert care of our orthopaedic colleagues.

They will need artificial limbs and time to learn how to walk again. All of these patients will have permanent scars, some of which may require surgical treatment over many years.

All of these patients, their families and loved ones, will bear permanent psychological scars, the effects of which cannot be underestimated. Psychiatrists and councillors and occupational therapists will be working with them now and in the future to help them all come to terms with their injuries and losses.

David Ross MD FRCS is Senior Registrar in Plastic Surgery at the Royal Free and the University College London Hospitals    

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