This study aims to determine and compare the effectiveness of Drop, Cover, and Hold On versus Fetal Position in the Triangle of Life regarding reducing casualties during earthquakes and establishing a consensus among medical search and rescue experts.

In this study, the data collected from ten experienced medical search and rescue professionals were analyzed using a three-stage Delphi technique to compare Drop, Cover, and Hold On versus Fetal Position in the Triangle of Life.

At the end of the first round of Delphi, all of the experts mentioned the following factors: age, position, and surface area of the injured person. A victim’s time under rubble and the experience of search and rescue teams are two prominent factors related to search and rescue. After the earthquake simulation in the second round, mannequin damage rates were examined by opening rubble pavement and tunnels. Following the second round of ratings, a third round of questionnaires was administered. As part of this questionnaire, participants were asked to give a score from one to ten based on their level of agreement. Whether they agreed or disagreed with Fetal Position in the Triangle of Life and Drop, Cover, and Hold On using a ten-point Likert scale, and the agreement rates were measured and compared. Experts completed a comparison of the two positions in the third round.

According to this expert consensus, the Fetal Position in the Triangle of Life has the following advantages over Drop, Cover, and Hold On: reduced surface area, less crush injuries, protection of a larger body part from injury, better protection from hypothermia, and better maintenance of basal metabolism.

During a major earthquake, escape attempts or collapsed buildings can result in injury, disability, and even death for victims. The aim of this study is to examine the demographic characteristics, clinical outcomes, and injuries of victims admitted to the emergency department within the first week after an earthquake.

This is a retrospective observational study conducted on earthquake victims who were admitted to the emergency services of a tertiary medical faculty and a training and research hospital in the city of Diyarbakir, located in the Southeastern Anatolia Region of Turkey, from February 6 through February 12, 2023.

Of the eligible 662 earthquake victims, the mean age was 10.66 (SD = 4.78 [min 0, max 17]) in children, 36.87 (SD = 4.78 [min 18, max 63]) in adults, and 72.85 (SD = 5.83 [min 65, max 84]) in the elderly. Women constituted 52.8% of the victims, 19.7% were children, and 8.0% were elderly. Sixty-one percent (61.0%) of earthquake victims were admitted to emergency services in the first three days following the disaster; 37.7% of all victims were transferred from other affected cities to Diyarbakır. In all, 80.2% of the victims were admitted as survivors to the emergency services (36.8% were rescued under rubble, 40.1% with injuries while attempting to escape the earthquake, and 3.3% with nontraumatic reasons) and 19.8% were deceased under rubble. The majority of the 131 deceased victims were women (52.7%), 20.6% were children, and 7.6% were elderly. An estimated 38.3% of victims were hospitalized (20.9% in the ward and 17.4% in the intensive care unit [ICU]). For all age groups that survived under the rubble, the extremities were most injured (53.6% for children, 53.1% for adults, and 55.5% for the elderly). Of adult survivors, 26.6% needed only fluid therapy, renal replacement treatment (hemodialysis) was required 20.7%, and 11.8% required amputation. Of children survivors under the rubble, renal replacement treatment (hemodialysis) was required for only four, seven required amputation, and 12 needed only fluid resuscitation for crush injury. Of elderly survivors, two needed only fluid therapy, renal replacement treatment (hemodialysis) was required for two, and no amputation was required. Six patients survived under the rubble and died in the ICU.

The definition of the demographic characteristics and clinical outcomes of earthquake patients is critical to the development of preparedness, response, and recovery policies for future disasters.

In Japan, evacuation at home is expected to increase in the future as a post-disaster evacuation type due to the pandemic, aging, and diverse disabilities of the population. However, more disaster-related indirect deaths occurred in homes than in evacuation centers after the 2011 Great East Japan Earthquake (GEJE). The health risks faced by evacuees at home have not been adequately discussed.

This study aimed to clarify the gap in disaster health management for evacuees at home compared to the evacuees at the evacuation centers in Minamisanriku Town, which lost all health care facilities after the 2011 GEJE.

This was a retrospective cross-sectional and quasi-experimental study based on the anonymized disaster medical records (DMRs) of patients from March 11 through April 10, 2011, that compared the evacuation-at-home and evacuation-center groups focusing on the day of the first medical intervention after the onset. Multivariable Cox regression analysis and propensity score (PS)-matching analysis were performed to identify the risk factors and causal relationship between the evacuation type and the delay of medical intervention.

Of the 2,838 eligible patients, 460 and 2,378 were in the evacuation-at-home and evacuation-center groups, respectively. In the month after the onset, the evacuation-at-home group had significantly lower rates of respiratory and mental health diseases than the evacuation-center group. However, the mean time to the first medical intervention was significantly delayed in the evacuation-at-home group (19.3 [SD = 6.1] days) compared to that in the evacuation-center group (14.1 [SD = 6.3] days); P <.001). In the multivariable Cox regression analysis, the hazard ratio (HR) of delayed medical intervention for evacuation-at-home was 2.31 with a 95% confident interval of 2.07–2.59. The PS-matching analysis of the adjusted 459 patients in each group confirmed that evacuation at home was significantly associated with delays in the first medical intervention (P <.001).

This study suggested, for the first time, the causal relationship between evacuation at home and delay in the first medical intervention by PS-matching analysis. Although evacuation at home had several advantages in reducing the frequencies of some diseases, the delay in medical intervention could exacerbate the symptoms and be a cause of indirect death. As more evacuees are likely to remain in their homes in the future, this study recommends earlier surveillance and health care provision to the home evacuees.

The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland’s (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care.

The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation.

Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide.

The C4 has played an integral role in the State of Maryland’s pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

Capillary refill time (CRT) is an indicator of peripheral circulation and is recommended in the 2021 guidelines for treating and managing sepsis.

This study developed a portable device to realize objective CRT measurement. Assuming that peripheral blood flow obstruction by the artery occlusion test (AOT) or venous occlusion test (VOT) increases the CRT, the cut-off value for peripheral circulatory failure was studied by performing a comparative analysis with CRT with no occlusion test (No OT).

Fourteen (14) healthy adults (age: 20–26 years) participated in the study. For the vascular occlusion test, a sphygmomanometer was placed on the left upper arm of the participant in the supine position, and a pressure of 30mmHg higher than the systolic pressure was applied for AOT, a pressure of 60mmHg was applied for VOT, respectively, and no pressure was applied for No OT. The CRT was measured from the index finger of the participant’s left hand.

Experimental results revealed that CRT was significantly longer in the AOT and did not differ significantly in the VOT. The cut-off value for peripheral circulatory failure was found to be 2.88 seconds based on Youden’s index by using receiver operating characteristic (ROC) analysis with AOT as positive and No OT as negative.

Significant results were obtained in a previous study on the evaluation of septic shock patients when CRT > three seconds was considered abnormal, and the cut-off value for peripheral circulatory failure in the current study validated this.

Foreign body airway obstruction (FBAO) is a life-threatening emergency, and the prognosis of patients with FBAO is greatly affected by the prehospital process. There are only a few large-scale studies analyzing prehospital process databases of the fire department.

The aim of this study was to investigate whether characteristics of patients with FBAO were associated with prehospital factors and outcomes.

In this retrospective observational study, patients transferred to the hospital by the Tokyo, Japan Fire Department for FBAO from 2017 through 2019 were included. The association between neurologically favorable survival among the characteristics of patients with FBAO and prehospital factors affecting the outcomes was evaluated.

Of the 2,429,175 patients, 3,807 (0.2%) patients had FBAO. The highest number of FBAO cases was 99 (2.6%), which occurred on January 1 (New Year’s Day), followed by 40 cases (1.1%) on January 2, and 28 cases (0.7%) on January 3. The number of patients who experienced out-of-hospital cardiac arrest (OHCA) caused by FBAO was 1,644 (43.2%). Comparing the OHCA and non-OHCA groups, there were significant differences in age, sex, time spent at the site, and distance between the site and hospital. Cardiac arrest was significantly lower in infants after FBAO (P < .001). In total, 98.2% of patients who did not have return of spontaneous circulation (ROSC) before hospital arrival died within 30 days, a significantly higher mortality rate than that in patients who had ROSC (98.2% versus 65.8%; P < .001).

Among patients who did not have ROSC following FBAO upon arrival at the hospital, 98.2% died within 30 days. Thus, it is important to remove foreign bodies promptly and provide sufficient ventilation to the patient at the scene to increase the potential for ROSC. Further, more precautions should be exercised to prevent FBAO at the beginning of the year.

In the last ten years, Japan has experienced several large-scale earthquakes with devastating social and health impacts. Earthquakes directly and indirectly cause a variety of health problems. Further investigation is required to increase preparedness and preventive efforts. In response to the Hokkaido Eastern Iburi Earthquake on September 6, 2018, 32 Emergency Medical Teams (EMTs) employed the Japanese version of Surveillance in Post-Extreme Emergencies and Disasters (J-SPEED) as a national standard daily reporting template, gathering data on the number and type of health problems treated.

The purpose of the study is to conduct a descriptive epidemiology study using the J-SPEED data to better understand the health problems during the earthquake disaster.

Reported items in J-SPEED (Ver 1.0) form were analyzed by age, gender, and time to better understand the health issues that have arisen from the earthquake.

Most consultations (721; 97.6%) occurred between Day 1 and Day 13 of the 32-day EMT response. During the response period, disaster stress-related symptoms were the most common health event (15.2%), followed by wounds (14.5%) and skin diseases (7.0%).

The most often reported health event during the response period was stress-associated illnesses related to disasters, followed by wounds and skin conditions. The health consequences of natural disasters depend on diverse local environment and population. As a result, this initial study was hard to generalize; however, it is expected that data accumulated using the J-SPEED system in the future will strengthen and extend the conclusions.

Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation.

The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments.

The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator.

In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources.

The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.

The ever-growing penetration of internet and mobile technologies into society suggests that people will increasingly use web searches to seek health-related information, including advice on first aid in medical emergencies. When a bystander is incompetent in first aid and has no immediate support from Emergency Medical Services (EMS), as it happens in low-resource settings or in disasters, instructions found online could be the sole driver for administering first aid before arrival of professional help.

The aim of this study was to evaluate quality of advice on first aid generated by a web search engine’s question-answering system (QAS) in response to search queries concerning provision of help in common health emergencies.

In December 2022-January 2023, an English-language search was carried out in Google with ten queries based on the keyword combinations (what to do OR how to help) AND (bleeding OR chest pain OR choking OR not breathing OR seizure). The search engine’s QAS responses (up to 11 per search query) were evaluated for compliance with the International Federation of Red Cross First Aid Guidelines 2020 using the pre-developed checklists.

Out of 98 QAS items generated by Google, 67.3% (n = 66) were excluded, mainly because the QAS answers did not address original queries. Eligible unique QAS responses (n = 27) showed poor coverage of the guideline-compliant instructions on first aid. Mean percentage of QAS responses providing a first aid instruction with complete adherence to the guidelines varied from 0.0 for choking to 19.5 for seizure. Only three (11.1%) QAS responses contained an explicit instruction to access EMS, while 66.7% (n = 18) included directions either contradictory to the guidelines and potentially harmful (eg, use of home remedies in chest pain) or inapplicable for an untrained person (eg, use of tourniquet in bleeding).

Although the search engine’s QAS responds to user’s inquiries concerning assistance in health emergencies, the QAS-generated answers, as a rule, omit potentially life-saving evidence-based instructions on first aid and oftentimes give advices noncompliant with current guidelines or inadequate for untrained people, and thus create risks for causing harm to a victim.

This study aimed to determine the long-term mortality (one-year follow-up) associated with patients transferred by Emergency Medical Services (EMS), and to reveal the determinants (causes and risk factors).

This was a multicenter, prospective, observational, controlled, ambulance-based study of adult patients transferred by ambulance to emergency departments (EDs) from October 2019 through July 2021 for any cause. A total of six Advanced Life Support (ALS) units, 38 Basic Life Support (BLS) units, and five hospitals from Spain were included. Physiological, biochemical, demographic, and reasons for transfer variables were collected. A longitudinal analysis was performed to determine the factors associated to long-term mortality (any cause).

The final cohort included 1,406 patients. The one-year mortality rate was 21.6% (n = 304). Mortality over the first two days reached 5.2% of all the patients; between Day 2 and Day 30, reached 5.3%; and between Day 31 and Day 365, reached 11.1%. Low Glasgow values, elevated lactate levels, elevated blood urea nitrogen (BUN) levels, low oxygen saturation, high respiratory rate, as well as being old and suffering from circulatory diseases and neurological diseases were risk factors for long-term mortality.

The quick identification of patients at risk of long-term worsening could provide an opportunity to customize care through specific follow-up.

Ethiopian policy and strategy aim to make health care systems capable of dealing with emergencies. However, Ethiopian health care still lacks a comprehensive “all-hazard” approach and a disaster preparedness program. Thus, this study aimed to assess the level of disaster preparedness in selected public hospitals for mass-casualty incidents (MCIs) in Amhara Regional State, Northwest Ethiopia.

A descriptive cross-sectional study was conducted at general and comprehensive specialized hospitals (CSHs) in Amhara Regional State, Ethiopia using a World Health Organization (WHO) hospital emergency response checklist that included a domain on mass-casualty management (MCM) adapted from a literature review.

Seventeen (17) hospitals were evaluated (response rate: 81%). Five (29.4%) were teaching hospitals (tertiary health care) and 12 (70.5%) were non-teaching (secondary health care) hospitals. With an average mean of 97.3 (SD = 33.68; range 31-160), most hospitals under WHO required an Acceptable level of preparedness. Two were at an Unacceptable (0-67) level of preparedness, 12 (70.5%) hospitals were at an Insufficient (68-134) state, while the other three had an Acceptable (135-192) level of preparedness.

The preparedness level of hospitals is Insufficient for potential MCIs in this region and needs prior attention in implementing existing strategic guidelines to develop and activate hospital disaster plans if and when needed.

Sports venues foster community and support local economies. Due to their capacity to host hundreds to thousands of spectators, sports venues are vulnerable to becoming targets of terrorism. Types of venues targeted, regional trends, and methods of attack employed world-wide have not been well-described.

A search of the Global Terrorism Database (GTD) was conducted from 1970 through the end of 2019. Pre-coded variables for target type “business” and target subtype “entertainment/cultural/stadium/casino” were used to identify attacks involving venues where sports events might be viewed by spectators as part of an audience. Sports venues were specifically identified using the search terms “sport,” “stadium,” ”arena,” and “ring,” as well as mention of any specific sport. Two authors then manually reviewed each entry for specific information to confirm appropriateness for inclusion, selecting preferentially for attacks against venues where watching a sports event was the primary focus for the majority of the attendees. Descriptive statistics were performed using R (3.6.1).

Seventy-four (74) terrorist attacks targeting sports venues were identified from January 1, 1970 through December 31, 2019. Thirty-three (33) attacks, or 44.6% of attacks, involved soccer stadiums or soccer venues, while 33.8% of attacks (25 attacks) involved unspecified sports venues. A bombing or explosion was the most frequent method of attack employed, comprising 87.8% of attacks. The highest number of attacks occurred in the Middle East & North Africa. In total, 213 persons died and 699 more were wounded in attacks against sports venues.

Although terrorist attacks against sports venues are uncommon, they carry the risk of mass casualties, especially when explosives are used. A greater understanding of the threat posed by terrorist attacks against sports venues can aid emergency preparedness planning and future medical responses.

The aim of this review was to summarize current evidence from the United States on the effectiveness of practices and interventions for preventing, recognizing, and controlling occupationally acquired infectious diseases in Emergency Medical Service (EMS) clinicians.

PubMed, Embase, CINAHL, and SCOPUS were searched from January 1, 2006 through March 15, 2022 for studies in the United States that involved EMS clinicians and firefighters, reported on one or more workplace practices or interventions that prevented or controlled infectious diseases, and included outcome measures. Eleven (11) observational studies reported on infection prevention and control (IPC) practices providing evidence that hand hygiene, standard precautions, mandatory vaccine policies, and on-site vaccine clinics are effective. Less frequent handwashing (survey-weight adjusted odds ratio [OR] 4.20; 95% confidence interval [CI], 1.02 to 17.27) and less frequent hand hygiene after glove use (survey-weight adjusted OR 10.51; 95% CI, 2.54 to 43.45) were positively correlated with nasal colonization of Methicillin-resistant Staphylococcus aureus (MRSA). Lack of personal protective equipment (PPE) or PPE breach were correlated with higher severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity (unadjusted risk ratio [RR] 4.2; 95% CI, 1.03 to 17.22). Workers were more likely to be vaccinated against influenza if their employer offered the vaccine (unadjusted OR 3.3; 95% CI, 1.3 to 8.3). Active, targeted education modules for H1N1 influenza were effective at increasing vaccination rates and the success of on-site vaccine clinics.

Evidence from the United States exists on the effectiveness of IPC practices in EMS clinicians, including hand hygiene, standard precautions, mandatory vaccine policies, and vaccine clinics. More research is needed on the effectiveness of PPE and vaccine acceptance.

Disaster Medicine (DM) is defined by Koenig and Shultz as the “disciplines and organizations involved with governmental public health, public and private medical delivery including Emergency Medical Services (EMS), and governmental emergency management.” The Accreditation Council for Graduate Medical Education (ACGME) sets curriculum requirements and standards for Emergency Medicine (EM) residencies and EMS fellowships, which include a limited portion of the DM curriculum topics recommended by the Society of Academic Emergency Medicine (SAEM). The ACGME does not currently approve DM fellowships, as DM is not recognized as a subspecialty by the American Board of Medical Specialties (ABMS). This lack of nationally standardized guidelines for DM training leads to variability in disaster-related knowledge and skills, even among physicians trained by ACGME-accredited programs.

The objective of this study is to analyze the DM components covered in EM residency and EMS fellowship in the United States and compare those to SAEM DM fellowship curriculum guidelines.

The DM curriculum components of EM residencies and EMS fellowships were evaluated, using the SAEM DM curriculum as a control. Overlapping topics, as well as gaps between the programs, were analyzed using descriptive statistics.

Of the DM curriculum components developed by SAEM, EMS fellowship covered 15 of 19 (79%) major curriculum components and 38 of 99 (38%) subtopics, while EM residency covered seven of 19 major curriculum components (37%) and 16 of 99 (16%) subtopics. Together, EM residency and EMS fellowship cover 16 of 19 (84%) major curriculum components and 40 of 99 (40%) subtopics.

While EMS fellowship covers a large portion of the DM major curriculum components recommended by SAEM, there are several important DM subtopics that are not covered either in EM residency or EMS fellowship. Furthermore, there is no standardization for the depth and manner that DM topics are addressed in either curriculum. Time constraints in EM residency and EMS fellowship may also prevent extensive review of important DM topics. Disaster Medicine covers a distinct body of knowledge, represented in the curriculum subtopics, that are not covered in either EM residency or EMS fellowship. The development of an ACGME-accredited DM fellowship and recognition of DM as a distinct subspecialty could allow for more effective DM graduate medical education.

Disaster Medicine (DM) requires skills, knowledge, and prior experience that are rarely put to test by health care providers. Pediatric DM presents unique challenges in terms of both knowledge and practice.

An anonymous survey consisting of demographic and five-point Likert scale questions was administered to physicians, nurses, and other medical personnel from Israel’s major medical emergency teams who were deployed to respond to the refugee crisis in Ukraine. This included teams from the Hadassah and Tel Aviv Sourasky Medical Centers and the Israel Ministry of Health.

Of the 171 members of the medical teams deployed on the Ukraine border, a total of 105 responses were obtained (61.4%) from 61 physicians, 50 nurses, and 12 other health care providers. The teams were composed of pediatricians (31.6%), internal medicine physicians (21.6%), Emergency Medicine and intensive care physicians (18.0%), and 31.0% other specialties.

For 60% of the participants, this was their first deployment, and 78% had received no training in DM. Members rated the need for DM training at 4/5 (IQR 3-5). Forty-nine (49) members (46.6%) were not briefed on situational awareness and 97 members (89.5%) were not trained in the recognition of acute stress reactions. The responders also rated their concerns about providing medical aid to children at 2/5 (IQR 1-3). A medical clown was part of the teams 42.8% of the time; the presence of clowns was rated at a median of 4/5 (IQR 4-5). The team members underscored the need for more targeted training in DM at 5/5 (IQR 3-5).

The findings highlight the need for the formulation of a disaster education model that includes pediatric DM.

This scoping review explored the main environmental factors in the workplace that contribute to nursing resilience in respiratory infectious pandemic events.

There is strong evidence in the literature about the influence of individual factors on nurses’ resilience and a growing interest on the impact of the workplace environment on these factors. Therefore, a review that synthesizes environmental factors that support nurses’ resilience in pandemic events is timely.

A scoping review of publications written in English, Spanish, and Portuguese of registered publications until December 2020 in MEDLINE, Embase, PubMed, Scopus, SciELO, CINAHL, WoS, BVS, and APA identified 10,767 potential papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines were used during the literature review process. The Health Services Workplace Environmental Resilience Model (HSWERM) was used to guide exploration and synthesis.

Thirty-two (32) publications met inclusion criteria. Most of the HSWERM workplace factors were mentioned in the literature. The main workplace environmental factors that were identified included communication, inter-professional collaboration, access to equipment, targeted training, and supporting well-being.

Recognition of these key environmental factors in the workplace will help to implement more effective actions to promote resiliency prior to and during emergency situations. It will also enable managers to include, in any preparation planning, contingencies to protect these factors with the view of sustainable resilience of nursing staff throughout the emergency event.

The use of chemical, biological, radiation, and nuclear (CBRN) weapons is not new, and though rare, it is an issue of concern around the world due to their ability to cause large-scale mass-casualty events and their potential threat to global stability. The purpose of this study is to explore the use of CBRN weapons by non-state actors through analysis of the Violent Non-State Actor (VNSA) CBRN Event database, and aims to better inform health care systems of the potential risks and consequences of such events.

Data collection was performed using a retrospective database search through the VNSA CBRN Event database.

A total of 565 events were recorded. Five hundred and five (505) events (89.4%) involved single agents while 60 events (10.6%) involved multiple agents. Fatalities numbered 965 for chemical agents, 19 for biological agents, and none for radiological and nuclear events. Injuries numbered 7,540 for chemical agents, 59 for biological agents, 50 for radiological events, and none for nuclear attacks. Fatality and injury per attack was 2.22 and 17.37, respectively, for chemical event agents and 0.15 and 0.48, respectively, for biological event agents.

Violent Non-State Actors were responsible for 565 unique events around the world involving the use of CBRN weapons from 1990-2020. The United States (118), Russia (49), and Iraq (43) accounted for the top three countries where these events occurred. While CBRN events remain relatively rare, technological advances have the potential to facilitate the use of such weapons as part of a hybrid warfare strategy with significant repercussions for civilian health and health care systems.

Russia’s annexation of Crimea in 2014, and the recent Russo-Ukrainian war that started in 2022, were triggers that radically changed the perception of security in the Nordic and Baltic countries. The on-going Russian hybrid war has resulted in a renewed global interest in the safety and security of many countries (eg, the Nordic-Baltic Eight). The prospective North Atlantic Treaty Organization (NATO) membership of Finland and Sweden may drastically change the regional military and political landscape.

The objective of this study was to identify and characterize all documented terrorist attacks in this region as reported to the Global Terrorism Database (GTD) from 1970 through 2020.

The GTD was searched using the internal database functions for all terrorism incidents in the Nordic-Baltic states: Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway, and Sweden.

Temporal factors, location, target type, attack and weapon type, perpetrator type, number of casualties, and property value loss were collated. Results were exported into an Excel spreadsheet for analysis.

There were 298 terrorism-related incidents from 1970 through 2020. Most attacks occurred in Sweden, followed by Norway and Finland. No entries were recorded for the Baltic states prior to their independency in 1991. The 298 incidents resulted in a total of 113 fatalities and 277 injuries.

Facility/infrastructure attacks were the most frequently identified attack type (35.0%), followed by bombings and explosions (30.9%). Armed assaults were responsible for 80 fatalities and 105 injuries, followed by bombings/explosions with 15 fatalities and 72 injuries. The predominant target types were immigrants and refugee shelters (64/298 incidents). In only 33.6% of the incidents, perpetrators were known. Right-wing assailants represented the largest group, accounting for 27 incidents.

From 1970 through 2020, there were 298 terrorist attacks in the Nordic-Baltic Eight. Sweden accounted for 50% of incidents.

The profile of terrorist attacks was very diverse, as were the perpetrators and targets. Every country had its own incident characteristics. The surge of right-wing extremism must be closely monitored.

Terrorist attacks against hospitals and health care providers have disproportionally increased during the last decades. A significant proportion of these attacks targeted abortion clinics and abortion providers. In the light of the overturning of Roe v. Wade in 2022, an increase of anti-abortion terrorist attacks is anticipated. Therefore, it becomes imperative to gain further insight into the risk and characteristics of past terrorist attacks. This study aimed to review terrorist attacks against health care targets providing abortion services from 1970 through 2020.

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorist attacks against abortion health care providers from January 1, 1970 - December 31, 2020. Temporal factors, location, attack and weapon type, and number of casualties or hostages were analyzed using descriptive statistics.

In total, 262 terrorist attacks were identified in five different countries. The majority (96.6%) occurred in the United States, with the highest counts during the last 20 years of the 20th century. Facility and infrastructure attacks were the most common attack types, followed by bombings and explosions. The attacks resulted in 34 injuries and nine fatalities. Kidnapping took place in three incidents. Of all successful attacks, 96.9% resulted in property damage.

Abortion-related health care facilities and providers have repeatedly been the target of terrorists over the past decades. Nearly all of these attacks took place in the United States, with the highest counts during the last 20 years of the 20th century.