The London nail bombings: the St. Thomas’ Hospital experience

Abstract

At 18:00 h on 17 April 1999 a nail bomb exploded outside a supermarket in Brixton, London. This was the first of a series of three identical nail bombs. The injuries were due to penetrating nails, most were relatively minor, with only three patients requiring general anaesthesia for removal of nails and debridement. One 6-year-old child subsequently underwent onward referral for neurosurgical treatment.

At 18:40 h on 30 April 1999, the third bomb exploded (there were no casualties at our hospital from the second bomb, that in Brick Lane on 24 April 1999) in the confined environment of the Admiral Duncan public house in Soho. The injuries were much more severe than those seen from the Brixton bomb. Two persons died on the scene and 81 were injured; 27 were transferred to our hospital. Three primary lower limb amputations were performed. Within the first 24 h, four patients required ITU care and two onward referral to the regional burns unit.

Injuries such as those seen in these two bombings are common in war situations. In peacetime it is rare to see this spectrum of injury and hence surgeons can be unaware of optimal management protocols. Our approach in these patients, based on thorough initial debridement and delayed closure/split skin grafting is similar to that advocated by the International Committee of the Red Cross based on their war surgery experience. We emphasise debridement without any initial reconstructive procedures. We also discuss some logistic problems of major incidents.

Introduction

During April 1999, three nail bombs exploded in central London, each targeted at different minority groups. St. Thomas’ Hospital received casualties from two of these bombings, those in Brixton and Soho. This paper compares the spectrum of injury seen in the two bombs and critically appraises the management both of the initial major incidents called as well as the subsequent surgical and rehabilitative care.

Brixton was the first of the three bombs, exploding outside a supermarket in a busy shopping precinct on the evening of 17 April 1999. Shortly before detonation the holdall in which the bomb was placed had been recognised as a suspicious package and moved to a more remote location by a security guard.

Forty-five people were injured in the explosion, they were taken to King’s, St. Georges and St. Thomas’ Hospitals. St. Thomas’ Hospital was put on standby to implement its major incident policy; fortunately a full major incident was not necessary on this occasion. Eight patients were brought to St. Thomas’ Hospital, of which four were admitted, the others only having sustained minor wounds. Of those which were admitted, three required surgery.

The first of the three operative cases was a 22-month-old child with a nail embedded in the temporal bone. The second patient suffered an open ankle fracture. The third patient was a 17-year-old girl with a nail entry wound in her right popliteal fossa. The nail had eventually come to rest in the left gluteal region.

At 18:40 h on the evening of Friday, 30 April 1999, a bomb exploded inside the crowded Admiral Duncan pub in Great Compton Street, Soho.

Two persons were found to be dead on scene and 81 were injured. The casualties were taken to University College, St. Thomas’ and Charing Cross Hospitals. The Helicopter Emergency Accident Service (HEMS), based at the Royal London Hospital, also attended the scene.

At 18:55 h the London Ambulance Service declared a major incident, whereupon the major incident plan at St. Thomas’ Hospital was initiated. Twenty-seven cases were transferred to St. Thomas’ Hospital. Because the major incident was declared in the early evening there were still a reasonable number of staff either still in the hospital or in close proximity.

The A&E specialist registrar took charge of the major incident. She was assisted by the A&E sister. They organised resuscitation teams to be led by middle grade staff, since they are routinely exposed to trauma calls. There were many surgeons attending, including vascular, colorectal, orthopaedic, and plastic surgery consultants. Their role was to make the major management decisions and prioritise cases for theatre. A consultant radiologist located within the A&E Department was able to provide a rapid reporting service for trauma radiographs.

The large number of consultants allowed difficult decisions, such as the need for primary leg amputation, to be made quickly and by a consensus. Eight patients were admitted to St. Thomas’ Hospital, all of whom required surgery. Within 1 h of the first casualty arriving at St. Thomas’ Hospital there were multidisciplinary operating teams at work in four theatres.

The general pattern of injury was of multiple, severely contaminated fragment wounds, and open fractures. One patient was judged to need bilateral trans-tibial amputations and another needed unilateral trans-femoral amputation. Several patients suffered burns which were all partial thickness in severity. Only one patient required onward referral to the regional unit for treatment of his burns.

As soon as the eight severely injured patients had been resuscitated they were prepared for theatre. The initial surgical management concentrated on radical debridement of dead and contaminated tissue. Where necessary, primary amputations were performed. In limbs that were judged to be for reconstruction, fracture stabilisation was with external fixation. Debrided wounds were left open and dry, bulky dressings applied. The vascular, colorectal, orthopaedic and plastic surgeons together provided a multidisciplinary approach to the surgery of each patient. Anaesthetic staff conducted acute pain rounds from early the following morning.

The patients were returned to theatre 48–72 h later where the wounds were inspected under general anaesthesia. For those that were clean, delayed primary closure was undertaken or split skin grafting was commenced. For wounds that still contained dead or contaminated tissue, further debridement was performed. This process of wound care continued until healing, which in some cases took over 1 month. This was largely performed by the plastic surgeons and necessitated the use of considerable extra theatre time, sometimes at the expense of elective cases.

All the patients in both incidents were seen by the department psychiatric liason nurses and given written information to take away with them, including contact telephone numbers. This was particularly helpful for the patients that became deaf from the bomb blast.

All staff involved underwent debriefings and were given counselling where necessary. The briefings provided a useful forum for discussion on how to improve the management of major incidents and were also an informal social support medium for staff exposed to such a number of severely injured patients.