Event Identifiers

1. a) Event Type - Unplanned Explosions at Munitions Site (UEMS)

2. b) Event Onset Date - March 7, 2021

3. c) Location of Event - Military Base in Bata, the economic capital of Equatorial Guinea

4. d) Geographic Coordinates: 1º49'09"N 9º48'39"E, 42m

5. e) Dates of Observations Reported: March 11-19, 2021

6. f) Response Type: Humanitarian Medical Aid Mission

Sources

The report was approved by the IDF-MC’s Institutional Review Board.

Data regarding the structure of the delegation were collected from the delegation protocols. Data regarding the medical condition and treatments were obtained from IDF medical records. Statistical analysis was performed using SPSS statistical software version 21 (IBM Corp.; Armonk, New York USA).

All activities of the Israeli delegation were coordinated with the local government, which supported, hosted, and provided transportation for the Israeli team.

Observations

The Israeli team was the first international team to arrive at the scene and consisted of 53 medical personnel from different disciplines, as detailed in Table 1, nine HFC engineers, and five security team and spokesmanship.

Table 1. Composition of Medical Personnel

The team focused on two primary efforts:

1. 1. The medical teams focused on assisting and augmenting the local medical teams working at surge capacity since the explosion, increasing both the capacity and the capabilities of all three local hospitals; and

2. 2. The HFC teams performed damage assessment, ordnance survey, civil aid, and training for resilience improvement.

The medical personnel were divided into four teams. Three teams, one for each of the local hospitals: The General Hospital, Insesio Hospital, and La Paz Hospital. Each team included trauma surgeons, orthopedic surgeons, anesthesiologists, nurses, and operating room technicians. The teams operated a triage effort in the emergency departments of the local hospitals. They augmented the operating rooms and performed surgeries as well as continuous patient care in the hospitalization wards. The fourth team performed outreach activities in the villages surrounding Bata. Given that many patients did not reach the hospitals and did not seek medical aid in fear of the costs involved, the medical effort soon expanded beyond the local hospitals, treating ambulatory patients, and triaging those requiring hospital treatment, referring them to one of the hospitals. Together with the local MOH, an announcement was made on national television and radio based on the Israeli reinforcements. Wounded civilians were called to come to the hospitals free of charge, increasing the influx of patients. Notably, electricity and access to media were limited for many patients in the surrounding villages (where many victims fled, to join their families). Dedicated teams using loudspeakers affixed on pickup trucks were operated by local health officials and spread the word and invited casualties from the blast to seek medical care in IDF-MC field clinics. Untreated for days following the blast, many arrived with fractures, wounds, and infections, and new areas were reached daily. Two hundred thirteen patients were treated in these field clinics, mainly for minor injuries; 14 casualties were transferred to the local hospitals for further treatment.

A total of 231 patients were treated by the Israeli medical teams in the three local hospitals in Bata. The average age of patients was 24 years (range one month – 81 years), 96 (41.5%) were under the age of 18, 125 (54.1%) were adults older than 18 years old, and the age of 11 patients (4.4%) was unknown. Four patients were pregnant.

The main indications for medical treatment (a patient could have more than one indication) were open wounds (105; 45.5%), infections (48; 20.7%), medical problems (44; 19%), closed fractures (29; 12.5%), open fractures (5; 2%), ear nose and throat (ENT) and ophthalmology (13; 5.6%), general surgery and gynecology (15; 6.5%), and acute stress reaction (8; 3.5%). Overall, 27 (11.6%) patients underwent at least one operation, 13 (5.6%) for wound debridement, nine (3.9%) for fracture fixation, eight (3.4%) for a skin graft, five (2.1%) for amputations, and four (1.7%) for general surgery indications. Ten patients underwent more than one surgery. Eleven (4.7%) patients received one or a few nerve blocks, either as an addition to general anesthesia or as the main method of anesthesia. Two patients were treated with at least one whole blood unit (O positive low titer) brought from Israel in a particular cooling unit (Crëdo Cube, Series 4; Peli Biothermal; Maple Grove, Minnesota USA).

Three patients were treated with a negative pressure dressing. This technique was passed on to the local teams, and medical supplies for continuous treatment were left for the local teams. A portable ultrasound was used for diagnostic purposes of six patients and nerve block assistance in eight patients.

The local authorities reported that a total of 107 people were killed in the explosions and more than 700 people were wounded, including women and children. ¹

The COVID-19 pandemic was a new factor that influenced the operation of this humanitarian mission, as caution measures, all team members were vaccinated twice with Pfizer’s (New York USA) vaccine against COVID-19 at least two weeks prior to the departure; social distancing rules were established together with the use of face masks. A Polymerase Chain Reaction (PCR) test upon the team’s arrival back to Israel revealed that none of the team members was infected by the COVID-19 virus during the mission in Equatorial Guinea.

Analysis

The IDF-MC has long-term experience with deploying acute phase emergency medical teams (EMTs) to disaster zones. Such teams were deployed to Armenia (1988), ^{Reference Heyman, Eldad and Wiener2} Turkey (1999), ^{Reference Bar-Dayan, Leiba and Beard3} India (2001), Haiti (2010), ^{Reference Kreiss, Merin and Peleg4} Japan (2011), ^{Reference Merin, Blumberg, Raveh, Bar, Nishizawa and Cohen-Marom5} Philippines (2013), ^{Reference Glick, Baruch and Tsur6,Reference Albukrek, Mendlovic and Marom7} and Nepal (2015). ^{Reference Naor, Heyman, Bader and Merin8,Reference Bar-On, Abargel, Peleg and Kreiss9} In addition, EMTs were deployed to refugee crises in Rwanda (1994) and Kosovo (1999). Comparative studies have shown that different disaster scenarios and conditions pose unique challenges and require adaptive personnel and equipment solutions. ^{Reference Bar-On, Blumberg and Joshi10,Reference Bar-On, Lebel and Kreiss11} The situation in Bata was different due to the nature of the disaster. Unfortunately, UEMS are a growing problem, with more than 30 incidents in 2019. ¹² These explosions can lead to many fatalities and casualties like the Beirut August 2020 explosion that led to more than 200 deaths, more than 6,000 injured, and more than 300,000 who lost their houses. ¹³

These UEMS differ from earthquakes in several manners:

1. 1. An explosion usually affects a single location and is a one-time situation with finite infrastructure damage, in contrast to natural disasters such as earthquakes and severe storms which cause severe infrastructure damage to a large area.

2. 2. The local hospitals are overloaded but remain operational.

3. 3. The injury patterns differ with more penetrating injuries in UEMS than crush injuries in earthquakes. In addition, UEMS cause severe blast injuries not encountered in earthquakes. ^{Reference Champion, Holcomb and Young14,Reference Smith and Garner15}

These differences were considered in the planning stage of the mission and influenced its design and personnel composition. Realizing that the local health system was still functional, the decision was not to deploy Israel’s World Health Organization (WHO; Geneva, Switzerland) certified Type 3 EMT, which can function as a full freestanding field hospital, but instead chose to reinforce and support the local health system with personnel and equipment. Another issue that influenced the selection of experts for the mission was the on-going COVID-19 burden in Israel when the team was formed. In contrast to previous missions, a larger percentage of regular army personnel were chosen for the mission, extracting fewer reserve physicians and nurses from the local hospitals.

The injury characteristics, as expected, indicate that the casualties treated by the Israeli teams suffered from explosion-related injuries such as penetrating injuries, fractures, burns, and severe soft tissue damage caused by the blast mechanism. Due to the arrival of the aid team 89 hours after the explosion, the team did not treat casualties with life-treating injuries and did not perform direct life-savings procedures. Many patients suffered from secondary infections that required antibiotic treatment, wound treatment, and debridement.

By understanding the expected challenges, the team was reinforced with the following supplements:

1. 1. A plastic surgeon with adequate equipment capable of performing skin grafts and local flaps as a definitive treatment after wound debridement;

2. 2. Portable ultrasound devices that the team brought to Bata gave the physicians a great advantage, especially for analgetic nerve blocks after operations and for diagnostic purposes (ie, echocardiography and abdominal scans);

3. 3. A large amount and variety of antibiotics that the team brought helped to treat all the infected wounds;

4. 4. Whole blood units and freeze-dried plasma that were used for severely injured patients in the intensive care unit; and

5. 5. Of note, the team did not include rehabilitation experts (ie, physiotherapy or occupational therapy), which were needed in some cases in the week following the injury. Those will be incorporated in the next mission of the IDF’s-MC.

Another important key for the success of this kind of medical aid delegation is the collaboration with the local medical teams, which was very successful. The Israeli team members felt that the local teams were very grateful for their arrival and the ability to reduce part of the burden that they dealt with. The collaboration enhanced patient care. It was a bilateral teaching and learning experience, both medically and culturally. The close relationship established during the team deployment enabled continued contact and consultation after its departure, and seven patients were subsequently flown to Israel for continued treatment. During the team stay in Bata, several guidelines were emphasized to the team members. The first was to treat the patients to the same standard as they treat patients in Israel. The second was to collaborate with the local teams, learn from them, and guide them with advanced techniques that they were not familiar with. Furthermore, to remember that they were guests for a limited period and after their departure, the local medical teams would have to stay and continue to treat those patients, so they must be familiar with the procedures and treatment methods.

After the arrival of the Israeli team, more international teams arrived, and combined efforts were formed. The tragedy in the city of Bata emphasized once more that in times of need, the international medical community can help significantly, save lives, and enhance recovery wherever needed.