Dr Javid Iqbal
Pellet gun injury in Maisuma firing, which left four young boys maimed is a glaring example of how even supposedly non lethal weapon could wreck havoc in Kashmir. The propagation that it may cause multiple superficial injuries flies in the face of evidence.
To study the highly lethal effect of the much propagated least lethal ‘Pellet Gun’ foursome of team visited SMHS hospital and while other members tried to soothe and assuage the feelings of young victims and provided need based relief, I collected the medical details of pellet injured boys.
‘Pellet Gun’ as a firearm does have a damaging effect, though of a different denomination in medical terms. Distance does count in this type of firearm-a high velocity bullet may penetrate the human flesh and damage internal anatomical structures-sensitive ones even from a distance, while as pellets fired from a pellet gun from similar distance may cause relatively minor injury. The closer aim is however a different story- the penetrating power increases and proportionally the damaging effect. Maisuma is a test case, where as per the testimonies, the pellet gun was fired from a close range, the gun being aimed at some youngman playing carom. We may now get down to assessment of these cases on our 2nd September visit, as we got a measure of what they had suffered:
(1) Yasir Rafiq Sheikh S/o Rafiq Sheikh aged 28 years, JKLF leader Yaseen Malik’s cousin suffered as per the testimonies furnished, pallet gun abdominal injury at close range. He was operated immediately on being brought to SMHS hospital, for the next four to five hours doctors battled to save his life. The operative findings were intestinal perforation, for which a portion of intestines was removed and the healthy ends rejoined (anastamosis)-resection and anastamosis might not have posed a problem, but the deadly pellets had resulted in intra-abdominal vascular injuries. The bleeding major vessels had resulted in drop in blood pressure [hypotension] and in spite of getting 10-15 units of blood, which amounts to replacement of major part of total blood in the vascular system, his blood pressure before being operated [pre-operative phase] during the operation [per-operative phase] did not stablise, until the bleeding in the vessels was controlled by surgical measures.
Prolonged phase of low blood pressure [hypotension] results in shock-defined as a state of circulatory collapse, where along with hypotension there is increase in pulse rate resulting from increased heart rate [Tachycardia] as heart tries to accelerate its working to pump in more blood into a failing circulation, however due to lowered total blood volume [blood flowing in vascular system] the distribution of blood in various body systems suffers. The earliest sign of this failing distribution is cold, clammy skin due to less cuteneous blood supply [blood supply through the skin]
Following control of bleeding vessels, the state of shock was reversed in case of Yasir. Shock, depending on how prolonged it is results in organ damage-one by one-a state called ‘Multiple Organ dysfunction system’ [MODS] shock may become irreversible, with fatal results. In Yasir’s case prolonged period of shock-collapsing circulation resulted in low respiratory status, so his respiration had to be supported-a measure undertaken when spontaneous respiration suffers and his kidney function suffered damage. The required blood has to flow through kidneys’ [renal blood flow] for functional viability, with drop in circulatory blood volume, renal blood flow suffers. Main kidney function is to make urine-much needed excretion to drain out waste products. Accumulation of such products in blood leads to toxic effects with fatal results.
Kidney damage due to low renal blood flow resulted in low urinary output in Yasir’s case [Oliguria] which eventually leads to no urinary output [anuria]. As Yasir started showing cumulative effect of accumulating toxins, he was dialysed on 2nd September, when we saw him first, as also on 4th-on our second visit, however his kidney function did show some improvement, as he passed 250-300 ml [normal 1500 ml/a litre and a half] of urine. Dialysis involves removal of toxic waste products by mechanical means, once the vital body function fails to perform. Kidney function could improve in his case, as the organ regenerates, however urine output has to stabilise, until then dialysis has to continue, as frequently as required.
Yasir’s treatment line faces other challenges; he is still on supported respiration and prolonged use of life support system [ventilator] that makes him breath has its own hazards, it may lead to a toxic lung-the infection would add to the risks, he is already facing. The ideal prognostic scenario could be Yasir’s weaning away from ventilator, but then his clinical and para-clinical parameters should match up-which includes blood gas study, a normal mix of gases-inhaled (breathed in) oxygen and exhaled (breathed out) carbon dioxide.
Earlier Taufiq Ahmad Lone S/o Mushtaq Ahmad Lone, aged 17 years from Nowopora-Lone Mohalla injured on 13th August- Nowhatta Chowk firearm victim admitted in ward 17, where Yasir is admitted-surgical ICU had multiple abdominal injuries-an operated case on life support system [ventilator] developed toxic lung, which was successfully combated. The teenager was off the support system [ventilator] and breathing spontaneously with a cheerful demeanour, when we re-visited him on 4th September. One would hope and pray for a similar outcome in Yasir’s case, as a competent team of high grade medical professionals are battling to save his life!
We may now move to other Maisuma cases seen on 2nd September
(2) Sajid Mushtaq S/o Mushtaq Ahmad Dar aged 19 was admitted and operated on the same day as Yasir- 30th August. Sajid too sustained multiple pellet injuries on right side of chest and right arm. The pellet injury in the chest resulted in injuring the liver which is covered by thoracic bony cage [ribs] he had hemoperitoneum [blood in abdominal cavity] after repairing the liver, he had peritoneal toilet carried out [washing of abdominal cavity] post-operatively Sajid was stable, though a live witness of how lethal ‘Pellet Gun’ could be.
(3) Ashfaq Jan S/o Mehraj-ud-Din, aged 17 nephew of Yasin Malik with multiple pellet injuries-back, left shoulder and left arm-he was stable as we visited him on 2nd September, some superficial pellets were removed in his case, the one in the chest was not touched. Surgical prudence demands not to touch a pellet or bullet in a sensitive location, which has not resulted in any damage; however the effort to remove it might induce an un-intended trauma to a sensitive structure. Otherwise left inside, these foreign bodies cause no harm
(4) Aaqib Dar S/o Gh. Mohd Dar aged 17 with multiple pellet injuries on left side-axilla, forearm and loin, he too was stable managed conservatively [without an operative procedure]
It stands amply demonstrated how lethal ‘Pellet Gun’ could be; it may not leave a gaping wound of entry like other firearm injuries, such as a high velocity bullet. At the point of entry, there may just be, what is labelled as ‘Puncture Wound’ once it enters it may penetrate vital structures like heart resulting in ‘Cardiac Temponade’ a condition where bleeding suppresses the activity of heart [cardiac activity] usually with fatal results, it may puncture the lung causing Pnumohemothorax [Pnumo for air, hemo for blood] a condition where air escapes from he punctured site of lung and mixes with blood-the bleeding could either be minor or major if a major blood vessel is ruptured. And as seen in Yasir’s and Sajid’s case, it may injure the inner vital organs and lead to numerous complications, as indeed Yasir is facing. Pellets may cause spinal injury, which may lead to wheel chair life. In limbs, they may result in piercing blood vessels and nerves, putting the survivability of limb in danger; to conclude it may affect the proverbial ‘life and the limb’!
The purpose of the documentation is to record the gross human rights violations and to know the first hand truth about these brutal incidents. The truth needs to be laid bare by an impartial probe of all cases. Home Minister Chidambaram has already as per reports talked of 17 cases, what about others? The probe must be widened, the truth acknowledged and justice done. There cannot be any reconciliation unless truth is acknowledged, that alone could pave way for a peaceful resolution of Kashmir issue.
Yaar Zinda, Sohbat Baqi
[Reunion is subordinate to survival]
