Journal of Conventional Weapons Destruction

Volume 6 Issue 3 The Journal of Mine Action Article 25

December 2002

High Energy Transfer Missile Wounds in the Siege of Sarajevo and Their Relation to Mine Injuries

J.P. Beavis University College London

J.M. Ryan University College London

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Recommended Citation Beavis, J.P. and Ryan, J.M. (2002) "High Energy Transfer Missile Wounds in the Siege of Sarajevo and Their Relation to Mine Injuries," Journal of Mine Action : Vol. 6 : Iss. 3 , Article 25. Available at: https://commons.lib.jmu.edu/cisr-journal/vol6/iss3/25

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percemage of fatalities (in purple). (M) and the velocity (V). This applies ro creating a vacuum rhar sucks in infected High Energy Transfer Ir is imeresti ng to note that the a wounding object whether it is a car, a air and contaminated material from chance of actually hitting rhe enemy was bullet or a fragments of a mine. clothes, etc. greatest with the spear, and with a fatal­ The acrual equation is: 3. The wounds are always infected, Missile Wounds in the Siege ity of 80 percent, it was the best of the Energy (E) = Mass (MY2 x Velocity both from the debris ofs hell or mine frag­ weapons. T he swordsman was more ac­ (V) n or E= M!2 X V'/2 ments and from the material sucked in curate, with l 00 percent fatality. He was By and large, the smaller the injur­ behind d1e f.1st-moving particles or buller. much less likely to hit his opponent, how­ ing object in war, the more accurate its 4. The tissues are literally torn apart of Sarajevo and their path. Therefore, anti-personnel weapons ever, who in turn would be close enough from the energy that is released by the to offer a- possibly fatal-response. were designed to be small er but to travel particles slowing down, and this is inde­ Slingshots and arrows had a very low hit at a greatly increased speed-hence the pendent of rhe direct effect of the missile Relation to Mine Injuries~ rate and medium fatality with arrows at effectiveness of a sniper's bullet. The debris. rhe wo rst. T his is a startling contrast with simple mathematics show rhar with an 5. Injuries to nerves and large blood Using the example of war-torn Sarajevo, the authors discuss high energy the success of the mediaeval English bow­ object of l 0 grams travelling at 10 vessels are 10 rimes more frequent than transfer wounds and their complications. Their findings can be extrapolated HMD men at Crecy and Agincourr. It surely in­ kilometres per minute, to double the mass in peacetime wounds. and applied to the injuries of mine victims. dicates that technological progress and will multiply the energy by 20 rimes 6. The patients are usually shocked RESPOM :E tactics, as well as the English attemion to (1 Ox2 = 20). But to double the velocity from blood loss, and delay in treatment ens hunted effi ciently. It is speculative, obligarory training, played a large part in wi ll increase the energy by 400 rimes is often fatal. FRCS DMCC 2 by J P Beavis, INTERNATIONAL rhe development of the bow before ex­ (20 = 20x20 = 400). Velocity is, there­ 7. Complex "shattered bone" frac­ Consultant Orthopaedic and bur distinctly poss ible, that not only the working for 1•ictims ofconflitJ V implements of hunting but also the psy­ plosive weapons replaced it. fore, the major factor in determining the tures usually occur. Trauma Surgeon, Senior T his primitive-though bloody­ energy content of a moving particle 8. Multiple sires of injury will occur. Lecturer and Deputy Director chological traits of the chase led to, or at least accentuated, the proclivity of our an­ arrows (Figure 1). form of wa rfare was changed completely These forms of injuries are desig­ Leonard Cheshire Centre of 6 by the invention of explosive devices. J1ated "High Energy Transfer Wounds," The Situation in Besieged Conflict Recovery, cestors to kill and maim their fellows. Our There arc also many archaeological Although these were initially an inaccu­ and can occur from any object that moves Sarajevo 1992- 1996 University College London modern fragi le and turbulent societies must examples of primitive and quire complex rate and relatively weak form of weaponry, with sufficient energy. There are particu­ and J M Ryan, MCh FRCS surely mirror rhe violence rhat erupted surgery, some of which may even have from conflicts over food, terrirory and sex. been effecrive! Some patiems survived they soon developed to combine high-hit­ lar properties of such injuries apart from The siege of Sarajevo was the long­ DMCC FFAEM Consultant in the initial severe wound. These should be Because early man possessed borh despite complex interventions. ting potential with lethal precision. est in modern rimes. lr was an example Surgery and Accident and considered in derail because they dem­ the tools fo r destruction and the tendency Wirh a shorr leap of over 20,000 The science of all weapons, and in of a method of warfare as old as recorded Emergency Medicine fact of all injuries, is ro direct sufficient onstrate why there is a high complica­ Professor and Director to use rhem, it is nor surprising thar there years, we learn that by the rime of rhe history, in which attrition is focused on energy into biological tissues ro disrupt tion rare even after good initial treatment, Leonard Cheshire Centre of is archaeological evidence of injuries and siege ofTroy, it was considered essential the civilian population with the ultimate them. All moving particles are possessed mmely rhe fo llowing eight reasons: Conflict Recovery, University their treatment. for all educated Greeks to understand aim of attacking the citizens psychologi­ 5 of a certain amounr of energy, and when 1. Massive tissue destruction is char­ College London After the invemion of representa­ simple medical care. cally and physically. As well as wounding 1 they are stopped or slowed by an object, acteristic of such wounds, and often the J P Beavis and J M Ryan are members of the tional art around 35,000 BC, scenes T he other information that we have and killing, the weapons used are those limb cannot be preserved. The missile, HMD Response International Medical and from the early societies are portrayed in of the Trojan siege is derived mainly from that energy is transferred to the object and of fear, uncertainty and deprivation. All whether it is a bullet or a piece of a mine Tech nical Advisory Board caves of Fran ce and Spain, but with very Homer's Iliad in which the author gives distorts or destroys ir. Soft animal tissue will suffer, but the sick and elderly, the 2 or shell, will fragment further and spread few acrually showing conflict or wounds. • 3 derailed accounts of the wounds. Frolich is particularly vulnerable and severe unborn children and infants, and the Historical Background Nevertheless, even at this early stage in has analysed Horner's work and demon­ wounds occur. violently through the tissues. wounded are particularly vulnerable to 2. The high speed of the missi le man's history, violence is demonstrated, strated that there was a variation in rhe Physics tells us that the amount of starvation and loss of basic amenities. causes cavities to form, destroying local In order ro survive as a carnivorous as in th e wall painting of an individual number of wounds (shown in red in Fig­ energy (E) within a moving object de­ T hat every one in Sarajevo was effectively tissue beyond the sire of rhe track and species, it was imperative that homo-sapi- who has obviously been struck by several ure 2) caused by each weapon and the pends on the combined effect of irs mass in the from line is reflected in the distri-

• (Left to Right} Figure 1: A detail of a cave wall painting from eastern Spain. The 120 victim has been struck by • NUMBER OF WOUNDS eight arrows and may be 100 • Figure3: trying to extract one. Perhaps • %OF FATALITIES Distribution of the first record of trauma wounded in surgery! (From the work of H 80 Sarajevo. 4 Breuil } Military 37% Figure 2: Relationship 60 Civilian 63% between wounds and ----· fatalities. 40 20 0 Spears Swords Arrows Slings

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for the surgical development. be stabilised to allow trearmenr of other temperature. As can be seen in Figure 8, there are • Figure 4:Wound RESULT NUMBER % injuries of the arteries and viscera. Exter­ • Poor circumstances of the patients, serious deficiencies in the intake of Vita­ Complications. FULL UNION GOOD FUNCTION 254 76.97 Management of the Soft nal fixation is rbe first choice, but which caused anorexia and depression, mins C, B12, B6 and Folate, which are ESTABLISHED NON UNION 20 6.06 Tissue Component of Coupland states8 that devices can be roo leading ro refusal of food. essential in tissue repair. Although no MAL UNION 28 8.48 High-Energy Wounds complex for adverse war simations. The • Poor-quality food that was unpal­ cases of scurvy were recorded, the poten­ CHRONIC OSTEOMYELITIS 22 6.67 reliability and simplicity ofSarafix proved atable and rejected. tial for it ro occur is obvious. AMPUTATION 6 1.82 The majority of the wounds treated ideal for this work. lt is easy to envisage a situation in It was important to try to quantify TOTAL 330 100 in the Sarajevo siege were from shell and The device was used ar many sires which a severely injured patient-with a the relationship between the care of pa­ bullet wounds. Because the population including complex pelvic injuries wirh 10 percent increase in nutritional require­ tients and the change in nutritional sta­ was confined so severel y, reaching mined bowel and vascular damage. ment from rhe effects of rrauma, lying in tus during the early winter months of • Union areas was in itself hazardous. Neverthe­ Despite the overall success of the a ward ar I 0" with a pyrexia of, say, 39" 1993/94; the obvious parameter to review less, because of the similarity of high en­ Sarafn; device (76.97 percent of a studied and suffering from anorexia for many was infection. A direct relationship was • Non union ergy transfer wounds, the principles of cohort), there were inevitable complica­ physical and emotional reasons- be­ observed between the reduction in food • Figure 6 treatment and the complications that tions, as shown in Figure 4. comes a victim of malnutrition. occur are entirely rei evant to a smdy of There are no simple complications HMO instituted a survey of the re­ c Mal union . . WORSE SCENARIO FOR PATIENT mme InJUries. of these wounds, and all cause consider­ lationship between malnutrition and War wounds are complex and inevi­ able persistent symptoms that are often wound infection in Sarajevo between FEEDING NOV'93 TO JAN '94 • Non union permanent. Osteomyelitis (6.67 percent) August 1993 and January 1994.9 Assess- • tably get infected. In the early months 100 of the first World War, British Army bas a particularly sinister recurrent and ment by Zec, Harper and Beavis in 1994 • • Amputation Medical Officers were inexperienced in debilitating effect over many years. An of food delivery in the winter months 8 o• • treating such terrible wounds, and a mas­ estimate suggests that 15,000 Bosnians of the survey (November-January) dem- Go •. suffer from this crippling disease. bution of wounded between military and strated the problems from the blockade sive number oflethal infections occurred. onstrated that no more than 60 percent .ao•. Gavrankapetanovic and Beavis re­ of the required food would reach the city civilians (Figure 3). offood convoys and the effects of a freez­ In 1915/ orders were given ro remove all due to roadblocks and weather prevent- 2 In the summer of 1993, the new ing winter. In Sarajevo, the temperature dead and foreign material and to never ported the results of radical treatment of o• . chronic osteomyelitis following Bosnian ing air support. As well as blockade, non-governmental organization (NGO) ranges from as high as 40° C in summer primarily close wounds. The technique rhere was inevitable loss of food by theft, U eeded Airlift Theft Aftet HMO Response International asked for ro - 15° in winter. The city is set on a high is known as debridement, from the war injuries and found that after an ini­ reducing the food ro a little over 40 per­ tefusal volunteers from British Orthopaedic and plateau surrounded by mountains that French to unsaddle or release. tial improvement, the incidence began to increase considerably after two years (Fig­ cent of the required amount. Finally, rhe supplies and an increase in wound infec­ Trauma Surgeons to assist their Sarajevo inhibit air transport, and the poor roads, This rested method was employed tion when the pin track sites of the Sarafix colleagues. As with all wars, nothing went already militarily blockaded, were ob­ in Sarajevo with great success with rhe ure 5). rejection offood by patients in all hospi­ 11 tals in peaceful circumstances is well­ device were inspected • entirely according to plan, but it began a structed by heavy snowfalls. addition of an anti-tetanus toxin and an­ recognised as a major problem,9 reduc­ Unfortunately, extra food could not presence of this NGO in Bosnia that still Medical supplies soon failed, and in tibiotics. Injuries near rhe buttocks were N utritional Problems in a ing rhe final amount to 25 percent. In be brought in by aircraft, despite the ob­ continues. particular, the devices for fixing fractures particularly at risk of such infection. Siege Situation the Sarajevo hospitals in winter, the cir­ vious case thar was made for considering By August 1993, the devastation of were exhausted within weeks of the be­ the wounded patients as vulnerable. over a year of war was obvious in the de­ ginning of hostilities. Undeterred, a lo­ Management of Fractures For patients with massive 111Juries cumstances of the injured were, despite the best efforts of the staff, truly terrible. stroyed buildings and the hospital wards cal external fixator was designed by an in High-Energy Wounds fro m bullets, shells and mines, the effects It is not surprising, therefore, that depres- filled with patients suffering from com­ engineer and two surgeons and produced of starvation and winter cold increased Conclusion sian, anorexia and rejection of unpalat- plex wounds. Surprisingly, considering in Sarajevo throughout the war. This de­ Stabilising fractures resulting from the incidence of infection. A study be­ able food contributed ro the malnutrition. the terrible circumstances in which the vice-the Sarafix- was used in all Bosnia such injuries is both imperative and dif­ tween September 1993 and january 1994 Sarajevo was besieged for nearly four A graphical scheme of such a scenario is surgeons had worked, the level of infec­ on over 3,000 patients. HMO Response ficult. The fractures are often multiple showed a massive rise in wound infec­ years, and during this time, the popula­ represented in Figure 6. tion was much lower than expected. This International provided a critical compo­ and very unstable, with considerable im­ tion. tion was subjected ro all the terrors of A further HMO study demonstrated was soon to change. nent of the fixture-its surgical steel planred debris. They must be managed It was considered that the injured modern warfare and massive deprivation. that the nutritional requirements of the The succeeding months demon- pins-as parr of its support programme without closure of the wound and must patient in Sarajevo was at risk from mal­ Demoralising the civilian population by nutrition for several reasons: patients were not satisfied and that this depriving them of their basic needs has became more obvious as the autumn pro­ • Figure 5 • Poor supply of essential nutrients. always been the aim of besieging armies 12 MONTHS AFTER TREATMENT • Increased requirement for protein, gressed (Figure 7). It can be seen that the throughout history, and Sarajevo was no 20% INCIDENCE OF INFECTION carbohydrates and micronutrients be­ pre-war nutritional status was in excess exception. 36 MONTHS AFTER TREATMENT cause of increased metabolic response to of the recommended levels and body Modern weapons primarily have an 10 47% INCIDENCE OF INFECTION inj ury. weight was also higher than optimum. anti-personnel role in civil wars of this • Increased requirement for endog­ It is rempring to speculate that the excess nature, and the incidence in Sarajevo of enous heat production during winter be­ of body fat in the Sarajevans protected high energy transfer wounds in the civil­ cause of inadequate hearing of the them from malnutrition during the first ian population reflects this fact. The well­ wards-five percent increase for every I oo severe win rer. tried immediate treatment of wound toi­ drop in temperature. Very significantly, dietary micronu­ let and adequate debridement, along with • Increased demand for nutrition trienrs such as vitamins greatly decreased srable fracture ftxation, proved once again with infection- 10 percent rise in calo­ during the early winter months of 1993/ to be effective in producing a satisfactory 11 rie requirement for each 1" rise in body 94 (figure 8). cohort of results . https://commons.lib.jmu.edu/cisr-journal/vol6/iss3/25 • 82 • • 83 • 2 Beavis and Ryan: High Energy Transfer Missile Wounds in the Siege of Sarajevo and Their Relation to Mine Injuries

• Figure 7. Nutrition Pre-War and During Survey of Autumn As Percentage of How NGOs Can Build Peace: Recommended Leve l s 250% Landmine Clearance and Victim Assistance 200% return to their work and farms. Peacebuilding and post-conflict reconstruction are multi-disciplinary from a A conceptual industry shi ft may be 1 5 Oo/o governance, organizational behavior, executive development and field perspective. raking place from advocacy/military/ Rarely, though, are the tools of competitive advantage, project planning and 100% humanitarian demining to "demining as conflict resolution software used to seek linkages with non-governmental agricultural preparation." This is 50% CJ Pre war organizations (NGOs) to coordinate resources, particularly to integrate the happening as individuals from academia • Nov- Jan disparate sectors of landmine and UXO clearance, victim assistance and and demining NGOs seek the expertise 0% resourcing across industries. One method is to employ "best practices" from ofsoil scientists, agrologists and those who K C a l s Protein Fat s C H O CJ HosJan developed countries proven to develop abilities for disabled farmers and youth in specialize in occupational therapy in 'All graphics courtesy ofthe authors. post-conflict countries as one of a number of agrarian and health care initiatives disabled farming. Every post-conflict The nutritional deprivation was ob­ References built around demining as agricultural preparation. The goal is for NGOs and country and community is facing jectively shown to be important in the government departments to change the rules of competition between post-conflict environmental and rural reconstruction wounded patients by a signifi cant rise in 1. Oppenheim, A.L. 1964: Ancient Contact Information Mesopotamia: Portmit ofa Dead Civilization. Chi­ communities by shifting organizational behavior to reflect quality of care as a issues. T he task fo r an NGO is to search the infection rate during winter months cago and London, Universiry of Chicago Press. HMO Response International measure of gaining donor support. for the linkages and common when the food supply fe ll well below the 2. Lcroi-Gourlm1, A 158 Le symbolisme des 23 Pembridge Square denominators, as well as network these required levels. In a war siruation where grandes signes dans lim parietal paefolithiqie. Bull London W2 4DR Longer-term planning requires disparate groups of individuals ro build a evacuation is nor possible and food sup­ Soc Pro!hisr Francaisc 55, 384- 398. by Maureen Morton 3. Manjo, G. 1975 The Healing Hr1nd Man industrial engineering, operations research, consensus across interest groups at home. plies are precarious, the injured patients Tel: + 44 (O) 20 7229 7447 and Wound in the Ancient World pp 19. Harvartl E-mail: [email protected] managemen t information systems, These vertical linkages are similar ro the must be considered a vulnerable group. Introduction Univcrsiry Press. logistics, manufacturing, human factors, linkages within the value chain- the way Aid agencies should concentrate on re­ 4. Breuil, H. 1920: Les Rodm p eintes de engineering and operations managemenr. supplier or channel activities are performed lieving rhis problem as parr of rheir over­ Minntndn, l:Anrhropolgie XXX, 1- 50 (Plate Il l Demining and the clearance ofUXO Derail). are necessary, extremely dangerous and Project tasks, both outside and inside a affects the cost or performance of a fi rm's all medical aid strategy. 3 5. Jaeger, W. 1944: f'aidein. New York, Ox­ technically complicated jobs that require coun try, need university/industry activities (and vice versa). In essence, we M ine injuries were not common ford Univcrsiry Press (vol. Ill). collaboration. NGOs determine resident must cultivate communities of practice. among the ci tizens of Sarajevo because G. Ryan, J.M. er al, I99 7 Ballistic Trauma­ cross-functional skills. In a post-confl ict skill-sets and academ ic and technical Ideas have been presented ro deminers enemy snipers and artillery confined Relevnuce in Pence and ~tr. Arnold, London. siruation, many of the most skilled have 7. "Memorandum - Trcarmcnr Oflnjuries in qualifications, as well as engage industries from a governance perspective to rhem ro a very localised life. Military per­ either fled th e community or lost their lives. War" HMSO 1915. and associations to support landmine and circumvent military technical sensitivities sonnel were most li kely to be injured by NGOs who are "first-in" deal with crisis 8. C oupland, R.M.I992 •· ~1r Surgery And UXO clearance activities, mine-clearance pe rtai n ing to demining an d UXO mines during frontline service. Those ci­ External Fixation." AO/ASIF Dialogue 5 (I) June management and life-or-death community awareness and victim assistance. Support remediation. Once clearance work can be vilians who were injured by mines had 6-7. stabilization. These organizations generally 9. Gavrankaperanovic, 1., J.P. Beavis, Djozic, infrastructure must be built with and by seen as agricultural pre paration , it usual ly left the city for various reasons should have a long-term mandate to S. Sverlana Djozic. "Osteomyelitis The Forgotten the communiries. 2 perceptually opens up new opportunities such as collecting wood fo r fuel. reconstruct communities, which requires Complication" Presented Ti·;lll ma Care Conference for victim assistance. It especially creates T he risks that these un fortunate in­ Edinburgh 200 I. detailed planning with different interest A Firm Infrastructure program possibilities fo r disabled farmers d ividuals were prepared to take just to I 0. Lennard-Jones, J E 1992 '/1 Positive Ap­ groups and donors. prorlch To Nutrition As Trerttment. "London; Kings in developed countries to help their warm their families or ob tain meagre T here are many n ational and Fund. NGOs specializing in mine and UXO counterparts, disabled farmers and disabled amounts of food are an indication of the international organizations that play a role II. Beavis, J P. Medical Comequmces ofSiege clearance must interface with other types deminers in landmine communities. The te rrible effects of siege warfare on ordi­ Wrtrfore on a Modern City- Sttmjevo 1992-1995, in address ing the problems of landmine of NGOs: medical, advocacy, technical, sim ilarity ofoccupational and farm injuries nary people. • Thesis for DMCC London 2002. survivors; a Mine Acrion Center (MAC) should involve the relevant organizations. academic, societal, institutional and such as upper or lower extremity Included in this group are organizations of religious-all of whom must collaborate amputations and especially double or triple • Left to Ri ght: Estimated% Of Recommended Dally % Infected Sarafix Pin Tracks with government departments a nd amputations, requires the knowledge and Fig ureS. survivors. Such consumer organizations are lnta k e of M lc ronutrlents In Patients· militaries. Sadly, programs that do the coping skills of those who have lived the Fig ure 9. Diet Jan· 94 August 1 993- January 1994 important targets ofed ucation, information and training, particularly in the areas of self physical demining and true victim real ity. The poorest of deminers, if they help, maintenance of devices and the need assistance are seri ously under-funded survive an explosion, have ro face life SO 'Yo 3 0 •. for accommodations, supports and follow­ worldwide. Although expectations have severely disabled. T he status of the disabled 50 'Yo 2 s~. 27 up care. Because so many landmine victims been raised , the demand cannot be in society is one ofexclusion and alienation, 4 0'Yo 2o•• are children, special attention must be satisfied. To reduce post-conflict problems, which leads to a perception of the disabled 1 s•. 4 3 0'Yo 32 0 P II rack directed towards the needs of those who financial backing and a sense of urgency as "less than human." 1 o•. 26 20'Yo s•. are growing and developing, and for whom are needed to clear land and provide Only those rehabilitation programs 10'Yo 0 •• l..d__I!:===:LJ!:::::==L~ most prostheses or orthoses will have a occupational programs to allow both that solve attitudinal problems by O'Yo~~--~--~----~--L-~~--~--~~ A u gust Nov Jan '94 1 ampurees and able-bodied individuals ro developing and proving ability in the newly VtiC 8 12 BS '93 '93 limited period of util ity. ~ Blockade ~

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