This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting prehospital emergency response.

A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul.

On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims.

The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.

The New Mexico-1 Disaster Medical Assistance Team (NM-1 DMAT) has responded to more disasters due to hurricanes than disasters from any other type of event. To assess whether defined patient needs may be applied to future hurricanes, the patient needs after Hurricanes Andrew and Iniki were compared. The study question was, “Did patient medical needs differ after these hurricanes?”

Design: Retrospective cohort review. Subjects: All patients evaluated by NM-1 DMAT following Hurricanes Andrew and Iniki. Observations: Age, past medical history, chief complaint, diagnosis, diagnostic tests, treatments, triage level, and disposition. Age was analyzed using Student's t-test, other data were analyzed using the chisquare test.

A total of 1,056 patients were evaluated. Age distributions did not differ between events. More patients had co-morbidities after Hurricane Andrew. The only difference in chief complaint was that more patients complained of “cold” symptoms following Hurricane Iniki. The only differences in diagnoses were for upper respiratory infections, which were diagnosed more often after Hurricane Iniki. There were no differences in the administration of tetanus toxoid, antibiotics, or analgesics. Patients evaluated after Hurricane Andrew had more diagnostic tests performed and a higher illness/injury acuity. The proportion of the total number of patients conveyed to a hospital did not differ.

Patient needs were similar after Hurricane Andrew and Hurricane Iniki and may be applicable for predicting the needs of patients for future hurricanes.

To investigate the relative distribution of hazards causing hospital evacuations, thereby to provide rudimentary risk information for hospital disaster planning.

Cases of hospital evacuations were retrieved from newspaper and publication databases and classified according to hazard type, proximate and original cause, duration, and casualties. Both partial and full evacuations were included. The total number of evacuation incidents for all hazards were compared to the total number of hospital incidents for the one hazard, fire, for which national data is available.

There were 275 reported evacuation incidents from 1971–1999, with an annual average of 21 in the 1990s, the period for which databases were more reliable. The most, 33, were recorded in 1994, the year of the Northridge Earthquake. Of all incidents, 63 (23%) were attributable primarily to internal fire, followed by internal hazardous materials (HazMat) events (18%), hurricane (14%), human threat (13%), earthquake (9%), external fire (6%), flood (6%), utility failure (5%), and external HazMat (4%).

More than 50% of the hospital evacuations occurred because of hazards originating in the hospital facility itself or from human intruders. While natural disasters were not the preponderant causes of evacuations, they caused severe problems when multiple hospitals in the same urban area were incapacitated simultaneously. Clearly, as hospitals are vulnerable to many hazards, mitigation investments should be assessed not in terms of single-hazard risk-cost-benefit analysis, but in terms of capacity to mitigate multiple hazards. In view of the many qualifications and limitations of the dataset used here, but value of such data for disaster planning, hospitals should be asked to submit standardized incident reports to permit national data gathering on major disruptions.

Search and rescue helicopters from the Royal Norwegian Air Force conduct ambulance and search and rescue missions in the Barents Sea. The team on-board includes an anesthesiologist and a paramedic. Operations in this area are challenging due to long distances, severe weather conditions, and arctic winter darkness.

One-hundred, forty-seven ambulance and 29 search and rescue missions in the Barents Sea during 1994–1999 were studied retrospectively with special emphasis on operative conditions and medical results.

Thirty-five percent of the missions were carried out in darkness. The median time from the alarm to first patient contact was 3.3 hours and the median duration of the missions was 7.3 hours. Forty-eight percent of the missions involved ships of foreign origin. Half the patients had acute illnesses, dominated by gastrointestinal and heart diseases. Most of the injuries resulted from industrial accidents with open and closed fractures, amputations, and soft tissue damage. Ninety percent of the patients were hospitalized; 7.5% probably would not have survived without early medical treatment and rapid transportation to a hospital.

Using a heavy search and rescue helicopter in the Barents Sea was the right decision in terms of medical gain and operative risk.

Multiple casualty incidents (MCI) are infrequent events for medical systems. This renders audit and quality improvement of the medical responses difficult. Quality tools and use of such tools for improvement is necessary to ensure that the design of medical systems facilitates the best possible response to MCI.

To describe the utility of incident reporting as a quality monitoring and improvement tool during the deployment of medical teams for mass gatherings and multiple casualty incidents.

Voluntary and confidential reporting of incidents was provided by members of the disaster medical response teams during the period of disaster medical team deployment for the 2000 Sydney Olympic Games. Qualitative evaluations were conducted of reported incidents. The main outcome measures included the nature of incident and associated contributing factors, minimization factors, harm potential, and comparison with the post-deployment, cold debriefings.

A total of 53 incidents were reported. Management-based decisions, poor or non-existent protocols, and equipment and communicationrelated issues were the principal contributing factors. Eighty nine percent of the incidents were considered preventable. A potential for harm to patients and/or team members was documented in 58% of reports, of which 76% were likely to cause at least significant harm. Of equipment incidents, personal protective equipment (33%), medical equipment (27%), provision of equipment (22%), and communication equipment (17%) predominated. Personal protective equipment (50%) was reported as the most frequent occupational health and safety incident followed by fatigue (25%). Predeployment planning was the most important factor for future incident impact minimization.

Incident monitoring was efficacious as a quality tool in identifying incident contributing factors. Incident monitoring allowed for greater systems evaluation. Further evaluation of this quality tool within different disaster settings is required.

Injuries are a public health problem in developing countries resulting in major financial and productivity losses. Injuries in vulnerable populations, such as refugees, make an even greater impact on loss of life. Afghan refugees in Pakistan continue to form one of the world's largest refugee populations. This study systemically reviews the literature to estimate the magnitude and prevalence of intentional and unintentional injuries in Afghan refugees, and explores the implications of the findings for refugee healthcare policy and development of potential interventions specifically for Afghan refugees.

Electronic databases of MEDLINE, POPLINE, Refworld, and Winspirs were searched. In addition, a web search was conducted and specific organizational websites were reviewed. The search in developing countries was limited to studies in English or with an English abstract for the years 1966–2001.

The literature review identified patients with reported war injuries who presented to hospitals. Injuries to extremities (45%) were more frequent than injuries to the head or neck (36%, p <0.001), and thorax/abdomen (14%, p <0.001) regions. A majority of the injuries were caused by explosives, which included landmines (32.5%), fragmentations, such as shrapnel (33%), and firearms (27%). The mean incidence of mortality in these studies was 11%.

Despite such an extensive search, limited information was found pertinent to injuries in Afghan refugees residing in refugee camps. This dearth of literature on the prevalence of injuries, risk factors, and outcomes among this vulnerable group is a research and policy gap for public health. Specific quantitive and qualitative studies in this field are required to shape refugee healthcare policies and develop intervention programs.