The 26–29 November 2008, terrorist attacks in Mumbai, have been referred to as “India's 9/11”. Violent events in Mumbai over the past six decades were researched to understand the changing pattern of violent injuries.

A complex, retrospective, descriptive study on terrorist events was performed, using event reports, legal reports, newspaper reports, and police and hospital lists. The distribution of victims to various city hospitals, the critical radius, surge capacity, and nature of interventions required were assessed. The profile of those killed in the attacks was noted by sex, nationality, and occupation. Besides the overall mortality and case-fatality ratio, the critical mortality was calculated based on the death rates among the critically injured.

In 51 violent events in Mumbai over a 60-year period (1950–2009), 1,582 people were killed and 4,145 were injured. In the Mumbai terrorist attacks of 2008, the financial loss due to direct physical damage was INR 847,612,971 (US$18.5 million). Among those killed, the average age was 33.4 years, 80% were male, and 12% were foreign nationals. The case-fatality ratio for this event was 36.2% and the mortality among the critically injured (critical mortality rate) was 11%. Among the injured, 79% were male and the average age was 33.21 years (three months–85 years); 38.5% of patients arriving at the hospitals required major surgical intervention.

The injuries of violent events in Mumbai have been changing due to the use of heavy firepower and explosives. Strengthening the public hospitals for trauma care is a medical counter-terrorism response for future terrorist attacks. These attacks have affected the lives of the common person in Mumbai, in terms of increased security checks, alerts, and fear of further attacks. These are areas of further research.

Three decades of internal conflict, displacing 300,000 civilians, in the Northern and Eastern Provinces of Sri Lanka ended in May 2009. Civilians affected by the fierce fighting in the proceeding months were ushered by the military into internally displaced persons (IDP) camps in an area called “Manik Farm” in Vavuniya District until they could be resettled. The Ministry of Health led the provision of health services to the displaced in coordination with the humanitarian health cluster at the national and field level immediately after of the war.

The Ministry of Health plans and reports were reviewed, along with reports from health sector partners and national and international guidelines on coordination in humanitarian relief operations. The way the Ministry of Health coordinated with health sector partners via the health cluster was different from other coordination models where military and civil administration were involved in providing humanitarian relief also was compared.

The review shows that the health sector coordination mechanism adapted in Sri Lanka had a clear leadership and guidance for health sector partners according to national plans and frameworks. It was indicated by better health outcomes like mortality and morbidity among displaced population in IDP camps in Manik Farm.

Terror struck Pune on 13 Feb. 2010 as a powerful bomb ripped apart a popular restaurant, killing nine people and injuring more than 45. A retrospective analysis of the injury patterns was done.

The CDC template, viz. “Bomb Surveillance Form” was used for the data collection, that was analyzed by SPSS version 15 software.

Of the 50 survivors transferred to the four nearby hospitals, 11 (22%) of them had severe life threatening injuries, with 19 patients (38%) having primary blast injuries, Secondary type of injury was seen in, and 22% had tertiary injuries. Orthopedic (24%) and burn injuries (36%) were prominent. The mortality rate was 16%.

The occurrence of MCI in an unexpected scenario overwhelms the medical resources and challenges the emergency medical facilities. Analysis of the injuries revealed that fatal outcome was related to presence of shock, severe lung, bowel injury, presence of more than four types of injury and greater than 50% burns.

Highlights the importance of being able to recognize the blast injury patterns and their management.

Inability to compare with other blast injuries due to several missing data.

Blast injury sustained in a small, enclosed space is one of the most serious and complicated forms of multiple trauma. Hospitals and civic authorities must be prepared to counter this menace of modem times. Not everything that is faced can be changed, but nothing can be changed until it is faced.

Sri Lanka's 28 year protracted civil conflict between the government forces and Liberation Tigers of Tamil Eelam (LTTE) in the North of country saw dramatic end by May 2009 when the military forces succeeded in crushing the LTTE. Around 300,000 people were displaced due to the conflict and they were settled in welfare villages established in the North.

The Government of Sri Lanka working in partnership with all other actors mounted a major humanitarian response to address the needs of the war displaced population. The Ministry of Health took a leading role in coordinating the health care programs for the Internally Displaced Population(IDP).

Higher morbidity and mortality observed during early phase of settlement of IDPs was due to the results of two scenarios, one being the conflict situation and its direct consequences that have caused injuries, disabilities and mental trauma among the population. The second being the result of the collapse of the health system in conflict affected areas, long period of displacement of people and the disruption of social structures that have led to the indirect consequences of increase of infectious diseases and worsening of chronic diseases. Ministry of Health used Daily Crude Mortality Rate (DCMR) to measure the success of the response. According to the Sphere Project guidelines that developed a set of minimum standards in a disaster situation, the DCMR should be 0.25 per 10 000 population for South East Asia. The emergency threshold level is 0.5 per 10 000 per day for this region.

Of the number of people reaching the IDP welfare villages in early stages of emergency phase in May, DCMR averaged to 0.7. The figure settled to less than 0.5 per 10000 in June 2009. Thereafter daily DCMR remained less than 0.5 indicating success of the provision of care for IDPS.

The last thing the world needs is another war.1 Everyday about 3000 people die and 30,000 people are seriously injured on the world's roads.2 Furthermore, for people who survive the crash, additional suffering and frustration occur because of administrative, legal, and social barriers.3 Since transport to hospital usually takes 30–45 minutes, the ‘golden hour’ in which 48% of deaths occur is spent mainly in the prehospital environment.4 On March 11, 2008 at 7:30 AM a very foggy morning, a major car crash occurred on the high way from Abu Dhabi to Dubai. Initial scene response was conducted by Abu Dhabi traffic police Abu Dhabi Police Ambulance and Rescue Sections helped by Dubai. Casualities were transported to 2 hospitals in Abu Dhabi; Al Mafraq and Al Rahba. The Authors describes Al Rahba hospital response that received 159 causalities (almost half of the causalities).

Three victims died immediately on scene. Most of the causalities were triaged and re triaged as Priority 3 (green), suffered from extremity trauma, were treated and discharged. Twenty patients were triaged as Priority 2 (yellow) and were admitted to the hospital, Three patients were priority one (red) were admitted to the ICU, one of them died 10 days later due to severe head and chest injuries.

In 2009, a Boeing 737 crashed near Amsterdam, traumatically injuring 126 people. In trauma patients, some injuries initially escape detection. The aim of this study is to evaluate the incidence of Delayed Diagnosis of Injury (DDI) and the effects of tertiary survey on the victims of a plane crash.

Data collected included documentations of DDI, tertiary surveys, Injury Severity Scale (ISS) score, Glasgow Coma Scale score, number and type of injuries, and emergency intervention. Clinically significant injuries were separated from non-clinically significant injuries. Comparison was made to a crash in the UK (1989), before advanced trauma life support became practiced widely.

All 126 victims were evaluated in a hospital emergency department; 66 were admitted with a total of 171 clinically significant injuries. Twelve clinically significant DDIs were found in eight patients (12%). In 65%, a tertiary survey was documented. The DDI incidences differed for several risk factors. Eighty-one survivors of the UK crash had a total of 332 injuries. Of those with > 5 injuries, 5% had a DDI, versus 8% of those with ≤ 5 injuries.

The DDI incidence in this study was 7% of the injuries in 12% of the population. A tertiary survey was documented in 65%; ideally this should be 100%. In this study, a high ISS score, head injury, > 5 injuries, and emergency intervention were associated with DDI. The DDI incidence in the current study was lower than in the UK crash.

EXPO 2010 Shanghai China attracted about 246 nations and international organizations as well as 73 million visitors from home and abroad. To provide good medical services to is a challenge.

Eight Level A hospitals are designated as EXPO Hospitals to provide advanced medical services to those who need critical care. There are five first aid stations in the EXPO park to provide first aid to EXPO visitors and staff. First aid at scene and emergency response are the emphasis. Practical, realistic, and systematic and forewarning emergency plans are made. An agile and efficient structure is organized. All EXPO staff members underwent first aid training, especially the CPR training and the use of AED. The public are trained for self rescue skills via different approaches and provided with first-aid kits. A medical rescue team is recruited; the team consists of Critical Care physicians, surgeons, anesthetists and nurses. The team is able to deal with different situations under all conditions. The team is a standing army, after the EXPO, the team will be responsible for providing medical services in the regional disaster rescue. Drills are performed periodically to practice the rescue skills, enhance the communication and cooperation among different government departments.

By joint efforts, a safe, wonderful and unforgettable EXPO was presented to the world. During the 184 days, medical personnel provided medical services to the 73 million visitors.

The medical preparedness for World EXPO should be practical, realistic, and systematic and forewarning. The public should have the easy access to the information and resources. Develop the contingency plans according to the real situation, ensure its timely updating and deliver training to every one involved. Drills should be performed periodically to practice the rescue skills, enhance the communication and cooperation among different government departments.

The Yale New Haven Center for Emergency Preparedness and Disaster Response (YNH-CEPDR) has worked in the United States with state and local health and medical organizations to evaluate critical decision making activities and to develop decision making tools and protocols to enhance decision making in a time sensitive environment. YNH-CEPDR has also worked with international organizations and US federal agencies to support situational awareness activities in simulated and real world events.

During this session YNH-CEPDR will share the best practices from recent events such as the H1N1 response and the Haiti Earthquake. Participants will be engaged in discussions regarding overall framework for successful information collection, analysis and dissemination to support decision making based on these experiences. This session will also incorporate concepts provided by the US National Incident Management System (NIMS) and the Incident Command System (ICS), specifically through the development of Situational Reports (SitReps), Incident Action Plans (IAP) and Job Action Sheets as methods to implement the framework and concepts discussed. Participants will be led through a series of scenario-based discussions to allow application of critical decision making factors to their organization. At the conclusion of the session, participants will be able to identify next steps for enhancing the synchronization of critical decision making and information analysis within their organizations.

The “Health Legal Preparedness Model” developed in the US aims to provide better health-related responses in times of emergency. It includes four components: (1) law; (2) competencies; (3) information; and (4) coordination.

The aim of this study is to examine the usefulness of the “Health Legal Preparedness Model” in the present state of affairs in the field of emergency preparedness in Israel.

A qualitative study was conducted. In-depth interviews were performed with leading experts in the past or at present in the Israeli emergency health system.

The Israeli healthcare system already has elements of the model in place at various levels. The relative perceived importance of each of the four aspects of the model varied between the experts. Of the four components, law and coordination were perceived as a major system concern. Training of specialists in emergency legislation was controversial. In addition, differences were found in the experts' perceptions as of the optimal way to operate the health system during an emergency. Variability also was found in the perception of the private sector growth and in the importance of its incorporation into emergency response plans. The study found that the emergency preparedness system resembles military practices in its conduct. Nevertheless, there is willingness toward mutual emergency systems drills, including aspects of legal preparedness.

The model already is applied partially in the Israeli emergency healthcare system. Results indicate that the Health Legal Preparedness Model might be useful in identifying gaps in emergency response plans. It also crystallized gaps related to optimal operation during emergencies in the country. Therefore, it is important to reach agreement upon solutions that will incorporate a regulatory guideline in order to improve the function of the emergency healthcare system.

Recent studies have discussed major deficiencies in the preparedness of emergency medical services (EMS) providers to effectively respond to disasters, terrorism and other public health emergencies. Lack of funding, lack of national uniformity of systems and oversight, and lack of necessary education and training have all been cited as reasons for the inadequate emergency medical preparedness in the United States.

A nationally representative sample of over 285,000 emergency medical technicians (EMTs) and Paramedics in the United States was surveyed to assess whether they had received training in pediatric considerations for blast and radiological incidents, as part of their initial provider education or in continuing medical education (CME) within the previous 24 months. Providers were also surveyed on their level of comfort in responding to and potentially treating pediatric victims of these events. Independent variables were entered into a multivariate model and those identified as statistically significant predictors of comfort were further analyzed.

Very few variables in our model caused a statistically significant increase in comfort with events involving children in this sample. Pediatric considerations for blast or radiological events represented the lowest levels of comfort in all respondents. Greater than 70% of respondents reported no training as part of their initial provider education in considerations for pediatrics following blast events. Over 80% of respondents reported no training in considerations for pediatrics following events associated with radiation or radioactivity. 88% of respondents stated they were not comfortable with responding to or treating pediatric victims of a radiological incident.

Out study validates our a priori hypothesis and several previous studies that suggest deficiencies in preparedness as they relate to special populations - specifically pediatrics. Increased education for EMS providers on the considerations of special populations during disasters and acts of terrorism, especially pediatrics, is essential in order to reduce pediatric-related morbidity and mortality following a disaster, act of terrorism or public health emergency.