Back to basics: managing gunshot injuries in East Timor

BACKGROUND: The management of patients following severe trauma requires a combination of skills. Among these are accurate clinical assessment, basic resuscitation measures, basic general surgical skills and techniques, good decision making and team leadership. More technically advanced imaging and investigations are often useful and can enhance clinical assessment but should not replace the basic elements. In situations where more advanced investigations are not available good outcomes can be achieved by application of the basic principles in trauma management and surgery. This article describes a mass casualty situation of gunshot wounds managed with limited resources and the outcomes. METHODS: A series of gunshot wounds managed in a single day at Dili National Hospital, Dili, East Timor is described. The presentation of the patients, initial assessment of injuries and haemodynamic stability are detailed in addition to the subsequent surgical treatment, complications and outcomes. The information was obtained from hospital records and personal recollection of the treating doctors. All injuries were documented with digital photography. All patients were managed by two surgeons who also supervised their postoperative course and reported on their outcomes. Surgical procedures on all of the patients were performed by the named two consultant surgeons and one basic surgical trainee. RESULTS: Fourteen patients were treated for gunshot injuries. All were single bullet injuries. Six trajectories involved the thoracic or abdominal cavity (one trajectory traversed both). Eight injuries were to limbs or soft tissue of the pelvis and included four compound fractures. Surgical intervention was needed for all patients ranging from emergency laparotomy for haemodynamic instability through to wound debridements. Thirteen patients survived and were discharged from hospital within 3 weeks. One patient died of uncontrolled haemorrhage. CONCLUSIONS: In the present series of gunshot injuries managed with limited resources a good outcome was achieved with the application of basic principles. The present series emphasizes the importance of basic trauma management as outlined in courses such as Emergency Management of Severe Trauma and the use of basic surgical techniques as taught during the Advanced Surgical training program.