Adaptations to practice and resilience in a paediatric major trauma centre during a mass casualty incident.

BACKGROUND: Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident. METHODS: A qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering. RESULTS: Five themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented. CONCLUSIONS: Our study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.

Community organizations and mental health after the 2013 Boston Marathon bombings.

OBJECTIVE: Disasters are place-based traumatic events, yet contemporary understandings of disaster recovery often do not consider the role of community organizations. We examine organization type and proximity as they relate to post-disaster mental health in a longitudinal study following the 2013 Boston Marathon bombings. METHOD: Residents of metropolitan Boston (N = 846) were recruited via a probability-based sampling strategy within weeks of the bombings and were surveyed several times over a two-year period. Residents of metropolitan New York (N = 941) were recruited and surveyed at the same time and used for comparison due to similarities in community demographics, geography, and disaster histories. We identified six different organization types nearby resident: safety-based organizations, religious organizations, educational organizations, child- and family-promoting organizations, health-based organizations, and voluntary community organizations. With possible environmental detriments (crowds and noise) or benefits of organizations amplified in areas closest to the resident, the concentration of these local organization types was examined at different distance-based boundaries. Contextual data for both communities came from the U.S. Census, Google Places API, and Guidestar. RESULTS: For Boston metropolitan area residents, having more safety-based organizations within a half-mile to one-mile area in the aftermath of the bombings was associated with poorer functioning six to seven months later and greater psychological distress two years later. However, the presence of more safety-based organizations in the one to three mile area was associated with decreased psychological distress two years later. More health-based and voluntary community organizations in the half-mile to one-mile area were also associated with fewer fears and worries about future adversity two years post-bombing. Exposure to the bombings and other community traumas moderated this relationship among Boston area participants. CONCLUSION: Results suggest that local community organizations are not merely buildings or structures but ecological sources of support to those in need after a disaster.

What do we know about suicide bombing?

In this article, the present status of our knowledge about the phenomenon of "suicide" bombing or "martyrdom" operations is identified. A review of many studies located at different levels of analysis is conducted, followed by an analysis and evaluation of the state of the research at each level. In addition, an exploration of the evolution in the characteristics of this tactic and the differences, if any, between subnational and transnational acts is undertaken. The conclusion identifies what we know and what may be appropriate for future research and public policy initiatives.

Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program.

BACKGROUND: Violent attacks on and interferences with hospitals, ambulances, health workers, and patients during conflict destroy vital health services during a time when they are most needed and undermine the long-term capacity of the health system. In Syria, such attacks have been frequent and intense and represent grave violations of the Geneva Conventions, but the number reported has varied considerably. A systematic mechanism to document these attacks could assist in designing more protection strategies and play a critical role in influencing policy, promoting justice, and addressing the health needs of the population. METHODS AND FINDINGS: We developed a mobile data collection questionnaire to collect data on incidents of attacks on healthcare directly from the field. Data collectors from the Syrian American Medical Society (SAMS), using the tool or a text messaging system, recorded information on incidents across four of Syria's northern governorates (Aleppo, Idleb, Hama, and Homs) from January 1, 2016, to December 31, 2016. SAMS recorded a total of 200 attacks on healthcare in 2016, 102 of them using the mobile data collection tool. Direct attacks on health facilities comprised the majority of attacks recorded (88.0%; n = 176). One hundred and twelve healthcare staff and 185 patients were killed in these incidents. Thirty-five percent of the facilities were attacked more than once over the data collection period; hospitals were significantly more likely to be attacked more than once compared to clinics and other types of healthcare facilities. Aerial bombs were used in the overwhelming majority of cases (91.5%). We also compared the SAMS data to a separate database developed by Physicians for Human Rights (PHR) based on media reports and matched the incidents to compare the results from the two methods (this analysis was limited to incidents at health facilities). Among 90 relevant incidents verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, highlighting the differences in results from the two methods. This study is limited by the complexities of data collection in a conflict setting, only partial use of the standardized reporting tool, and the fact that limited accessibility of some health facilities and workers and may be biased towards the reporting of attacks on larger or more visible health facilities. CONCLUSIONS: The use of field data collectors and use of consistent definitions can play an important role in the tracking incidents of attacks on health services. A mobile systematic data collection tool can complement other methods for tracking incidents of attacks on healthcare and ensure the collection of detailed information about each attack that may assist in better advocacy, programs, and accountability but can be practically challenging. Comparing attacks between SAMS and PHR suggests that there may have been significantly more attacks than previously captured by any one methodology. This scale of attacks suggests that targeting of healthcare in Syria is systematic and highlights the failure of condemnation by the international community and medical groups working in Syria of such attacks to stop them.

[A bomb attack in the Netherlands; how would we provide hospital care?] / Een bomaanslag in Nederland.

- There is an ever-present threat of large-scale incidents and disasters, such as terrorism and natural disasters.- Preparation and planning are the key to successful response to major incidents and disasters, which is why education, training sessions and exercises take place in the Netherlands.- Analysis of recent large-scale incidents in Europe and the USA emphasises the importance of adequate distribution of the wounded to centres where the correct care can be provided.- A major step has been taken in the Netherlands to provide for such an eventuality with the introduction of distribution plans for the wounded, and other initiatives such as a regional hospital disaster plan.- If a large-scale incident should take place the Netherlands also has a Major Incident Hospital at its disposal; this is a unique facility that can guarantee availability of 200 spare beds to the Netherlands healthcare system within 30 minutes.

The development and assessment of behavioural markers to support counter-IED training.

This article describes the method used to develop and test a checklist of behavioural markers designed to support UK military forces during Counter-Improvised Explosive Device (C-IED) training. IEDs represent a significant threat to UK and allied forces. Effective C-IED procedures and techniques are central to reducing risk to life in this safety critical role. Behavioural markers have been developed to characterise and assess non-technical skills which have been shown to be important in maintaining high performance in other safety critical domains. The aims of this study were two-fold. Firstly to develop a method which could be used to capture and assess operationally relevant behavioural markers for use in C-IED training relating primarily to non-technical skills. Secondly, to test the user acceptance of the behavioural marker checklist during military training activities. Through engagement with military subject matter experts, operationally relevant and observable behaviours seen in C-IED training have been identified and their links to stronger and weaker performance have been established. Using a card-sort technique, the content validity of each of the markers was assessed in addition to their detectability in an operational context. Following this assessment, a selection of the most operationally relevant and detectable behaviours were assimilated into a checklist and this checklist was tested in C-IED training activities. The results of the study show that the method used was effective in generating and assessing the behavioural markers using military subject matter experts. The study also broadly supports the utility and user-acceptance of the use of behavioural markers during training activities. The checklist developed using this methodology will provide those responsible for delivering instruction in C-IED techniques and procedures with a straightforward process for identifying good and poor performance with respect to non-technical skills. In addition it will provide a basis for the provision of focussed feedback to trainees during debrief.

The psychological and psychiatric effects of terrorism: lessons from London.

The 7 July 2005 bombings in London caused heightened levels of distress among some in the general community. This distress was most notable in Muslims and members of ethnic minority groups. These effects were transient for most. An estimated 30% of those who were more affected by the attacks, including victims and witnesses, developed psychiatric disorders as a result. An outreach program was set up to screen those who were exposed to potentially traumatic events and to offer them evidence-based treatment. This article discusses what lessons might be learned from studies of the general community and the screen-and-treat approach.

Assessment of medical reserve corps volunteers' emergency response willingness using a threat- and efficacy-based model.

The goal of this study was to investigate the willingness of Medical Reserve Corps (MRC) volunteers to participate in public health emergency-related activities by assessing their attitudes and beliefs. MRC volunteers responded to an online survey organized around the Extended Parallel Process Model (EPPM). Respondents reported agreement with attitude/belief statements representing perceived threat, perceived efficacy, and personal/organizational preparedness in 4 scenarios: a weather-related disaster, a pandemic influenza emergency, a radiological ("dirty bomb") emergency, and an inhalational anthrax bioterrorism emergency. Logistic regression analyses were used to evaluate predictors of volunteer response willingness. In 2 response contexts (if asked and regardless of severity), self-reported willingness to respond was higher among those with a high perceived self-efficacy than among those with low perceived self-efficacy. Analyses of the association between attitude/belief statements and the EPPM profiles indicated that, under all 4 scenarios and with few exceptions, those with a perceived high threat/high efficacy EPPM profile had statistically higher odds of agreement with the attitude/belief statements than those with a perceived low threat/low efficacy EPPM profile. The radiological emergency consistently received the lowest agreement rates for the attitude/belief statements and response willingness across scenarios. The findings suggest that enrollment with an MRC unit is not automatically predictive of willingness to respond in these types of scenarios. While MRC volunteers' self-reported willingness to respond was found to differ across scenarios and among different attitude and belief statements, the identification of self-efficacy as the primary predictor of willingness to respond regardless of severity and if asked highlights the critical role of efficacy in an organized volunteer response context.

'The city of our dreams'? The political and economic realities of rebuilding Britain's blitzed cities, 1945-54.

This essay examines the political and economic factors affecting the rebuilding of Britain's provincial blitzed cities following the Second World War. Historians of planning have been prolific in their research on this period, but only from the perspective of planning visions and their reality, not the detailed steps that had to be followed towards implementation. This essay argues that, beyond the exigencies of an austere economic situation, both the Investment Programmes Committee--a Cabinet-level committee--and the planning legislation in the 1940s deeply affected the progress of rebuilding. Cities had to deal with constraints both obvious and hidden. After the Second World War, Britons lived in a world built not only by the visions of architects and planners, but also by developers, builders, and the desires of local authorities all working within a national political and economic framework.

Assessment of psychological preparedness and emergency response willingness of local public health department and hospital workers.

This study sought to investigate the relationship between psychologically-related attitudes/beliefs toward public health emergency response among local health department (LHD) and hospital workers and their willingness to respond to a pandemic influenza emergency scenario and a radiological 'dirty' bomb scenario, to inform workforce resilience-building interventions. LHD and hospital workers participated in a survey based on an established threat- and efficacy-oriented behavioral model (the extended parallel process model) that focused on collection of the aforementioned attitudes, beliefs, and self-reported response willingness. Odds ratios associating psychologically-related attitudes and beliefs with self-reported response willingness were computed Perceived levels of psychological preparedness and support were shown to impact response willingness, with more pronounced effects in the radiological 'dirty' bomb scenario. Compared to those who did not perceive themselves to be psychologically prepared, those who did perceive themselves as prepared had higher odds of self-reported response willingness. The relationship of these perceptions and self-reported willingness to respond in all contexts, both scenarios, and both cohorts was influenced by perceived self-efficacy andperceived family preparedness.

Human rights violations during Israel's attack on the Gaza Strip: 27 December 2008 to 19 January 2009.

The Israeli attack on the Gaza Strip from 27 December 2008 to 19 January 2009 was characterised by gross, unprecedented human rights violations, which were the result of a deliberate political decision to overlook the loss of civilian lives in order to save those of Israeli soldiers. These violations included attacking medical personnel and civilians, impeding emergency medical evacuations, restricting health care for the civilian population, preventing referral to care outside the Gaza Strip and jeopardising distribution of medical supplies and food. This article will focus on the right to health of Palestinians under Israeli occupation by presenting case studies that have been collected by Physicians for Human Rights-Israel. It will emphasise how the Palestinian medical system has been stretched to its breaking point, severely and negatively affecting the provision of medical services; the consequences of denying patients referral to care outside the Gaza Strip; and other severe violations of human rights. It will conclude by reiterating that only the withdrawal of Israeli occupation from Palestinian land can guarantee the right to health of Palestinians.

The development of a quick-running prediction tool for the assessment of human injury owing to terrorist attack within crowded metropolitan environments.

In the aftermath of the London '7/7' attacks in 2005, UK government agencies required the development of a quick-running tool to predict the weapon and injury effects caused by the initiation of a person borne improvised explosive device (PBIED) within crowded metropolitan environments. This prediction tool, termed the HIP (human injury predictor) code, was intended to:--assist the security services to encourage favourable crowd distributions and densities within scenarios of 'sensitivity'; --provide guidance to security engineers concerning the most effective location for protection systems; --inform rescue services as to where, in the case of such an event, individuals with particular injuries will be located; --assist in training medical personnel concerning the scope and types of injuries that would be sustained as a consequence of a particular attack; --assist response planners in determining the types of medical specialists (burns, traumatic amputations, lungs, etc.) required and thus identify the appropriate hospitals to receive the various casualty types. This document describes the algorithms used in the development of this tool, together with the pertinent underpinning physical processes. From its rudimentary beginnings as a simple spreadsheet, the HIP code now has a graphical user interface (GUI) that allows three-dimensional visualization of results and intuitive scenario set-up. The code is underpinned by algorithms that predict the pressure and momentum outputs produced by PBIEDs within open and confined environments, as well as the trajectories of shrapnel deliberately placed within the device to increase injurious effects. Further logic has been implemented to transpose these weapon effects into forms of human injury depending on where individuals are located relative to the PBIED. Each crowd member is subdivided into representative body parts, each of which is assigned an abbreviated injury score after a particular calculation cycle. The injury levels of each affected body part are then summated and a triage state assigned for each individual crowd member based on the criteria specified within the 'injury scoring system'. To attain a comprehensive picture of a particular event, it is important that a number of simulations, using what is substantively the same scenario, are undertaken with natural variation being applied to the crowd distributions and the PBIED output. Accurate mathematical representation of such complex phenomena is challenging, particularly as the code must be quick-running to be of use to the stakeholder community. In addition to discussing the background and motivation for the algorithm and GUI development, this document also discusses the steps taken to validate the tool and the plans for further functionality implementation.

Books vs bombs? Humanitarian development and the narrative of terror in Northern Pakistan.

This article examines the role of humanitarian discourse and development in reconfiguring the contemporary culture of empire and its war on terror. It takes as its point of entry the immensely popular biographical tale, Three Cups of Tea, which details how the American mountaineer Greg Mortenson has struggled to counter terrorism in Northern Pakistan through the creation of schools. Even as this text appears to provide a self-critical and humane perspective on terrorism, the article argues that it constructs a misleading narrative of terror in which the realities of Northern Pakistan and Muslim life-worlds are distorted through simplistic tropes of ignorance, backwardness and extremism, while histories of US geopolitics and violence are erased. The text has further facilitated the emergence of a participatory militarism, whereby humanitarian work helps to reinvent the military as a culturally sensitive and caring institution in order to justify and service the project of empire.

Temporal indiscriminateness: the case of cluster bombs.

This paper argues that the current stock of anti-personnel cluster bombs are temporally indiscriminate, and, therefore, unjust weapons. The paper introduces and explains the idea of temporal indiscriminateness. It argues that to honor non-combatant immunity-in addition to not targeting civilians-one must adequately target combatants. Due to their high dud rate, cluster submunitions fail to target combatants with sufficient temporal accuracy, and, thereby, result in avoidable serious harm to non-combatants. The paper concludes that non-combatant immunity and the principle of discrimination require a moratorium on the use of current cluster munitions.

The 2006 war and its inter-temporal economic impact on agriculture in Lebanon.

The July 2006 war waged by Israel on Lebanon caused an estimated USD 1 billion of direct (financial) damage to infrastructure. However, it generated also significant indirect (economic/inter-temporal) costs. One sector that suffered considerably in this respect was agriculture, the main source of income for 30-40 per cent of Lebanese. This paper's main objective is to develop a methodology to estimate the total-direct and indirect-cost of the war to agricultural crop production, using an area of south Lebanon as a focal point. The indirect loss assessment viewed inter-temporal reductions in crop production values as the opportunity cost of not working fields due to the presence of unexploded ordnance (UXO). Various crops were evaluated for two scenarios (50 and 100 per cent damage due to UXO) over UXO-clearance periods of five and 10 years. The results indicate that any damage estimates that include only direct losses will under-estimate total losses by 80 and 87 per cent for the five- and 10-year periods, respectively.

Cultural consequences of miscarriages of justice.

Social science scholarship has tended to focus more on the causes than the consequences of miscarriages of justice. Within the literature on consequences, the overwhelming emphasis has been on individual consequences: psychological and material impacts on the wrongly convicted individual and, in some cases, other indirectly impacted individuals such as family members of the wrongly convicted and victims of the true perpetrator's future crimes. Some attention has been devoted to social harms, the impact of miscarriages of justice on the broader society within which they are situated, such as the undermining of the legitimacy of the criminal justice system. This paper focuses on what are called here cultural consequences of miscarriages of justice: the way in which some high-profile miscarriages of justice can shape the public's beliefs about some of the most basic "facts" about crime, such as the nature, prevalence, or even existence of certain categories of crime and the types of individual who tend to perpetrate particular types of crime. In this way, the paper argues, miscarriages of justice may have hitherto underexplored consequences: reshaping, based on false premises, the public's belief about the very nature of crime itself. This paper discusses three cases studies of miscarriages of justice that for varying periods of time created widespread false beliefs about the nature of crime in large segments of the public. The paper concludes by noting that the "righting" of these false beliefs was in most cases fortuitous. This suggests that unexposed miscarriages of justice may still be shaping popular beliefs about the nature of crime, and aspects of the public's current conception of crime may yet be based on false premises.