|Year : 2013 | Volume
| Issue : 4 | Page : 435-440
|The emerging trend in the epidemiology of gunshot injuries in the emergency department of a Nigerian tertiary hospital in a State without formal prehospital emergency medical services
Gabriel Uche Pascal Iloh1, Abali Chuku2, John Nnaemeka Ofoedu1, Ogbonna Hyginus Ugwele1, James Onyedikachi Onyekwere1, Agwu Nkwa Amadi3
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia state, Nigeria
2 Department of Ophthalmology, Federal Medical Centre, Umuahia, Abia state, Nigeria
3 Department of Public Health Technology, Federal University of Technology, Owerri, Imo state, Nigeria
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|Date of Web Publication||26-Feb-2014|
| Abstract|| |
Background : Gunshot injuries (GSIs) though a rarity in Nigeria before the Nigerian civil war have now become rampant with variable epidemiology. It is emerging as a common cause of trauma-related emergency hospitalizations. Aim: The study was aimed at reviewing the epidemiology of gunshot injuries in the emergency department (ED) of a Nigerian tertiary hospital over a 5-year period. Materials and Methods: This was a retrospective study of GSIs seen at the ED of Federal Medical Centre, Umuahia, Nigeria using data from medical records, patients' case notes, ED admission registers, and nurses' report books. The data collected included age, sex, place of the incidence, time of the incidence, time of presentation to the hospital, anatomic sites, and etiology of the injury. Results : The age ranged from 14 years to 80 years with mean age of 47 ± 8.1 years. There were 95 males and 22 females with a male to female ratio of 4.3:1. The three most common causes were armed robbery (31.6%), kidnapping (21.3%), and police brutality (17.9%). The incident predominantly affected the middle age group (57.3%), occurred mostly during the day time (72.6%), affecting mainly the lower limbs (65.8%) and majority (84.6%) of the victims presented 1 hour after the injury. None of the victims received prehospital care. Conclusion: There was variability in the epidemiology of GSIs with kidnapping and police brutality emerging among preeminent contributors and downward trend of armed robbery-related GSIs. The incident occurred predominantly during the day time and most victims presented late to the ED. Interventional strategies including the responsible security apparatus system are advocated.
Keywords: Emergency department, epidemiology, gunshot injuries, Nigeria
|How to cite this article:|
Iloh GP, Chuku A, Ofoedu JN, Ugwele OH, Onyekwere JO, Amadi AN. The emerging trend in the epidemiology of gunshot injuries in the emergency department of a Nigerian tertiary hospital in a State without formal prehospital emergency medical services. Ann Trop Med Public Health 2013;6:435-40
|How to cite this URL:|
Iloh GP, Chuku A, Ofoedu JN, Ugwele OH, Onyekwere JO, Amadi AN. The emerging trend in the epidemiology of gunshot injuries in the emergency department of a Nigerian tertiary hospital in a State without formal prehospital emergency medical services. Ann Trop Med Public Health [serial online] 2013 [cited 2019 Feb 22];6:435-40. Available from: http://www.atmph.org/text.asp?2013/6/4/435/127794
| Introduction|| |
Trauma is an important clinical and public health problem worldwide. , It is one of the preventable causes of morbidity and mortality in sub-Sahara African countries. , The etiologies of trauma in developed and developing countries are variable and include road traffic accidents and injuries, gunshot injuries (GSIs) among others. Globally, GSIs have been reported in Jamaica,  Finland,  United Kingdom,  United States of America,  Sri Lanka,  Italy,  Pakistan,  and South Africa.  Gunshot injuries in developed countries were largely due to homicidal and suicidal firearm-related violence. ,, In Nigeria, GSIs used to be rare before the Nigerian civil war of 1967-1970 but armed robbery-related GSIs have become very rampant in the recent years in urban, ,,, semiurban,  and rural  areas of the country.
Gunshot injuries refer to the injury or wound caused by firearms.  Recent reports in Nigeria have demonstrated religious violence as the common cause of GSIs in Northern Nigeria  while armed robbery-related GSIs are common in Southern Nigeria. ,, More so GSIs in Nigeria could result from political thuggery,  celebrations, and festivals  hunting expeditions,  assassinations,  cultism,  and communal clashes.  The changing political climate and socio-economic disorder have resulted in the unregulated influx of firearms and ammunition into the Nigeria nation. ,,, Hospital rates of trauma admissions resulting from GSIs have been reportedly variable in Nigeria depending on the socio-economic, religious, cultural, and political activities in the locality. ,, The reported hospital rates were 4.5%,  3.6%,  and 3.8%  in some Nigerian studies. Studies have also described the sites of GSIs to involve head and neck,  oro-facial region,  upper extremities,  chest,  and lower extremities. ,,,
Gunshot injury is becoming an important source of trauma-related morbidity and predisposes the victims to the risk of death. Gunshot injury patients present as traumatic emergencies to the Nigerian hospitals and sometimes are dramatic in their presentation. However, some of these patients may succumb to the injuries before presenting to the emergency department (ED) of the hospital.  Epidemiological characteristics of the victims and socio-environmental factors may have contributed to the pattern of presentation of GSIs in Nigeria. Although GSIs have varying epidemiology, the magnitude of trauma-related GSIs and critical care requires focus on primary prevention especially in Abia state where there are no formal prehospital emergency medical services  and "first there, first care" concepts in basic trauma care  are nonexistent. The elucidation of the epidemiology of GSIs therefore needs to be explored in the study area. This will aid in improving feasible initiatives for interventional strategies and other diverse preventive requirements.  Clinical and public health interventions for ballistic trauma services may not be useful if the current experience and epidemiological trend in the study area are not highlighted. The authors were therefore motivated to study the emerging trend in the epidemiology of gunshot injuries in the emergency department of a Nigerian tertiary hospital in a State without formal prehospital emergency medical services.
| Materials and Methods|| |
The ethical certificate was obtained from the Ethics Committee of the hospital.
This was a retrospective study of 117 gunshot injuries seen within a period of 5 years that spanned from June 2007 to June 2012 at the emergency department of Federal Medical Centre, Umuahia, a tertiary hospital in Umuahia, Abia state, South-eastern, Nigeria.
Umuahia is the capital of Abia state, South-East Nigeria. The State is endowed with abundant mineral and agricultural resources with supply of professional, skilled, semiskilled, and unskilled manpower. Economic and social activities are low compared to industrial and commercial cities such as Onitsha, Port Harcourt, and Lagos in Nigeria. Until recently, the capital city and its environ have witnessed an upsurge in the number of banks, hotels, schools, markets, industries, junk food restaurants in addition to the changing dietary and social lifestyles.
Federal Medical Centre, Umuahia is located in the metropolitan city of Umuahia. It is a tertiary hospital established with the tripartite mandate of service delivery, training, and research and serves as a major trauma referral center in Abia state and neighboring States of Imo, Ebonyi, Rivers, and Akwa Ibom states of Nigeria. It has facilities for primary, secondary, and tertiary health care.
The emergency department of the hospital serves as a trauma unit within the tertiary hospital setting of the Medical Centre. All trauma victims are first examined at the emergency department of the hospital before they are admitted for further management, discharged home or referred to other specialist hospitals.
Inclusion and exclusion criteria
The inclusion criteria were the availability of patient case notes and required data. The exclusion criteria included patients who were brought in dead to the hospital. These patients were not registered in the emergency department registers.
Data were collected using a data collection schedule form which was developed for the study. The secondary sources of data included emergency department admission registers and case folders of gunshot injury patients. These were supplemented with data from nurses' report books. The data collected included basic bio-demography of the affected persons in terms of age, gender, occupation; where the incidence occurred (place), time of the incidence (temporal factor), time of presentation to the unit, trauma intervention interval, motive and circumstances of the gunshot injury, and anatomical site of injury.
Operationally, time of attack was categorized into two: day time was defined inclusively as the time period from 6.00 am to 6.00 pm in Nigeria while night time refers exclusively to the time period from 6.00 pm to 6.00 am in Nigeria. Early presentation to the hospital meant that the victim arrived at the emergency department of the hospital inclusively within 1 hour of the occurrence of the gunshot injury while late presentation to the hospital meant that the victim arrived after 1 hour.
The results generated were analyzed using software Statistical Package for Social Sciences (SPSS) version 13.0, Microsoft Coperation, Inc. Chicago, IL, USA for the calculation of mean frequencies and percentages.
| Results|| |
The age of the study population ranged from 14 years to 80 years with mean age of 47 ± 8.1 years. There were 95 (81.2%) males and 22 (18.8%) females with a male to female ratio of 4.3:1 [Table 1]. The lower limbs were the most common anatomic sites involved (65.8%). Other anatomic sites included upper extremities (35.0%), abdomen (15.4%), chest (12.8%), head and neck (6.8%) [Table 2]. Eighty five (72.6%) of the incidences occurred during the day time while 32 (27.4%) occurred during the night time [Table 3]. Ninety-nine (84.6%) victims presented 1 hour after the injury while 18 (15.4%) presented to the emergency department of the hospital within 1 hour of the gunshot injury [Table 4]. None of the victims received formal prehospital emergency medical care. The three most common causes of gunshot injuries were armed robbery (31.6%), kidnapping (21.3%), and police brutality (17.9%) [Table 5].
|Table 4: Time interval between injury and hospital presentation of the victims of gunshot injuries|
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| Discussion|| |
This study has shown variations of the frequency of gunshot injuries (GSIs) in different age groups in the study area. The most affected age group was the middle age group (40-65 years). This finding is at disparity with the most affected age groups reported in Nigerian studies: 30-40 years reported in Enugu,  21-30 years in Port Harcourt,  21-40 years in Lagos,  20-40 years in Maiduguri,  and 18-40 years reported in other parts of the world such as Sri Lanka.  The higher frequency of GSIs among the middle age group in this study is probably explained by the fact that the middle age group are economically viable and active working class citizens who have economic and financial wealth that can be stolen by armed robbers or given as a ransom to the kidnappers.
This study observed a higher frequency of GSIs among the males compared to the females. This finding is similar to the reports from Enugu,  Port Harcourt,  Lagos,  Maiduguri,  Nigeria, and other parts of the world such as South Africa,  Pakistan,  and Italy.  The higher frequency of GSIs among male gender could be attributed to the observation that men are generally more exposed to violence. , In addition, other researchers have adduced that males are more aggressive in demonstrating resistance to perceived threat. ,
The study observed that most of the GSIs occurred during the day time. This finding is at variance with the reports from Nigerian studies in Enugu,  Port Harcourt,  Lagos,  and Maiduguri.  This may be attributed to the fact that the perpetrators of GSIs in the study area do not operate in the night. This could be an indication of the increasing level of desperation at which gun-related injuries are being committed in the study area. In Nigeria recently, perpetrators of crime-related GSIs carried out the dastardly act clandestinely with utmost secrecy and avoidance of the public awareness. That was why most gunshot-related crimes were previously done in the night because the perpetrators would not like to be linked with such activities. , At present, the perpetrators of crime-related GSIs attack the victims in the daylight and the victims are afraid of criminals who inflict a reign of terror on the Nigerian society with macabre.  The frightening activities of these criminals are better imagined than seen.
This study has demonstrated that the most frequent anatomical site of GSIs was the lower extremities. This is similar to the reports from Nigerian studies in Enugu,  Port Harcourt,  Lagos,  and Maiduguri.  This finding is dissimilar to reports from Irrua, Nigeria  where upper extremities were the most frequent sites and Peshawar in Pakistan  where head and neck sustained the highest GSIs. The predilection for the lower extremities could be attributed to the intention of the perpetrators to immobilize rather than slay their victims or to scare the passers-by.
This study found armed robbery-related GSIs of 31.6%. This finding is lower than that in previous reports in Nigeria: 34.8% was reported in Port Harcourt,  69.7% in Irrua,  80.0% in Lagos,  and 89.2% in Maiduguri.  These findings are at disparity with reports from other parts of the world such as Sri Lanka,  Italy,  and United States of America  where gang-related violence was the main motive behind GSIs. The lower frequency in the armed robbery-related GSIs in the study area could be a reflection of the change in the motive behind GSIs resulting in the downward trend of armed robbery-related GSIs and emergence of kidnapping-related GSIs. These armed robbers may have metamorphosed into kidnappers. The frequency and audacity in executing kidnapping-related crimes have shown that there is probably a huge financial reward involved in the venture. 
Kidnapping accounted for 21.3% of GSIs in this study. This emerging motive of gunshot-related crimes is probably an indication that kidnapping is considered by the perpetrators as being less risky crime than armed robbery and other high profile crimes with huge return on investment because of the ease with which it can be executed.  This could be attributed to the fact that the unwary and prospective victims of kidnapping do not move about with security unlike armed robbery which involves breaking into houses, banks or business premises with security where armed robbers may encounter security challenges and confrontations. The societal menace of kidnapping has created fear and anxiety among Nigerians in the study area. The social gatherings such as wedding ceremonies, burial rites, and church activities have become favorable poaching grounds for kidnappers and the citizenry are no longer sure of their safety and security. The predisposing risk factors of kidnapping include youth unemployment and frustration, family dysfunction resulting in the failure of the family to perform the fundamental task of providing its basic needs and socialization functions and the failure of government security apparatus especially the security agents to guarantee the security of the citizens.
The finding of police brutality-related GSIs of 17.9% is a cause for concern. In the past police brutality-related GSIs were rarely encountered in Nigeria.  However, in the recent times there is a rising wave of police brutality-related GSIs.  This is probably an indication of poor police-civilian relationship and a reflection of poor professionalism considering that the Nigerian Police were employed to protect the citizens. This implies that an erstwhile environment of relatively good police-civilian relationship is fast becoming an area of questionable security due to the activities of some members of the Nigerian Police in the study area. With increasing level of desperation to extort money from the society or get rich quickly by some unscrupulous members of the Nigerian Police, this trend of GSIs may continue unabated. This finding therefore brings to the front burner the issues related to the change in the professional attitude and practice of Nigerian Police toward the use of firearms.
Although the time interval between gunshot injury and arrival to the hospital is variable, 15.4% of the victims presented to the hospital within 1 hour of injury. Late arrival of the victims of the trauma-related GSIs to the hospital has been reported in different parts of Nigeria. ,, In Nigeria, there is passers-by inertia in helping the victims of trauma-related GSIs due to the problems of Nigerian Police in demanding for written statement of the incidence that led to the GSIs from the passers-by who acted as "good Samaritans" in bringing the victims to the hospital or demand by the hospital for the payment of the treatment for the victims. This therefore calls for public health information, education, and communication programs on the importance of helping the victims of GSIs to the hospital because a delay for a few minutes can lead to loss of life. More so, the late presentation to the emergency department of the hospital could be attributed to the lack of prehospital emergency medical services in Abia state.  The importance of prehospital trauma care system has been elucidated by World Health Organization. , With these constraints it appears that late presentation could have been prevented. Ensuring that gunshot injury victims receive prompt prehospital emergency medical services during the critical window of need is advocated in the study area.
The limitations of this study are recognized by the authors. First and foremost, the limitations imposed by the retrospective nature of the study using secondary data are appreciated by the researchers. Secondly, the sample size was relatively small, although this was the number of patients whose case notes met the inclusion criteria during the period under review. More so, victims who were brought in dead were excluded from the study. If these dead patients were inclusively considered, this could have added to the sample size. Thirdly, this study didn't assess for seasonal variations or proportion of trauma-related GSIs. This was due to the poor state of documentation of what happened during the interface with these victims of GSIs especially at the time of arrival, the time of discharge or referral and other diverse information. This suggested that the emergency department personnel are ignorance of the importance of documentation of the details of clinical encounter with emergency patients. The medico-legal implications of good record keeping must be emphasized in the study center in this era of increasing medical litigation.
| Conclusion|| |
There was variability in the epidemiology of GSI with kidnapping and police brutality emerging among preeminent contributors to the GSI spectrum in the study area. The incident occurred predominantly during the day time and most victims presented late to the emergency department. Interventional strategies including the responsible security apparatus system are recommended.
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Gabriel Uche Pascal Iloh
Department of Family Medicine Federal Medical Centre, Umuahia Nigeria, Umuahia
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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