Forensic Anthropology in Investigations of Crimes Against Humanity: Global Dimensions and the Mid-19th-Century Ajnala (India) Massacre.

Heinous crimes and brutalities have decimated humanity throughout human history. In modern times, forensic anthropologists have helped to reconstruct the nature and mechanism, intent and purpose, manner, and circumstances of various inhumane instances of genocides and violent crimes. Anthropologists endeavor to bring closure and comfort to bereaved families by disseminating information about the location, exhumation, and identification of the remains of victims. The methodological armamentarium and scope of forensic anthropology have developed much beyond the realms of the traditional biological profiling casework to the scenarios of humanitarian concerns. Humanitarian forensics focuses on the excavation and identification of the remains of victims and facilitates the dignified burial of the deceased. This review article highlights and exemplifies the significant contributions of forensic anthropological expertise in revealing various crimes against humanity and human rights violations committed in the recent past as well as in some contemporary cases reported from around the globe. It includes cases such as Guatemalan, Cambodian, and Bosnian genocides, as well as other mass killings that illustrate the efficacy of anthropological evidence in reconstructing the nature, mechanism, and circumstances related to these incidences. Special emphasis is given to the Ajnala (India) skeletal remains excavated from an abandoned well - remains reportedly belonging to 282 Indian soldiers killed in 1857 whose corpses were dumped into the said disused well by sanitary workers - indicating the importance of forensic anthropology in authenticating the occurrence of events as mentioned in historical records. Analysis of different case histories reveals that forensic anthropologists have played a significant role in recovery and identification of the victims of the many war crimes, genocides, racial conflicts, and violent cruelties committed against mankind in modern history.

Analysis of transfusion therapy during the March 2019 mass shooting incident in Christchurch, New Zealand.

BACKGROUND AND OBJECTIVE: A mass casualty incident occurred in Christchurch in March 2019. Thirty-seven patients with gunshot wounds were admitted. We describe and analyse the transfusion management of these casualties. METHODS: Data on demographics, injury and laboratory characteristics, and transfusions are summarized using descriptive statistics. Relationships between variables are examined using Pearson's and Spearman's rank correlations. Univariate analysis of explanatory variables is performed to determine the best early predictors of transfusion requirements. The characteristics of massive transfusion and non-massive transfusion cases are compared using the t- and Mann-Whitney tests. RESULTS: Sixty-five per cent received transfusions. Initial Hb, platelet counts and clotting results were mostly normal. On average, each gunshot wound patient was transfused 4, 3·1, 1·2 and 0·4 units of RBC, FFP, cryoprecipitate and platelets, respectively, on the day. Base excess was the single best predictor of transfusion requirements. CONCLUSIONS: A greater proportion of those with gunshot wounds in this incident were transfused than in other such incidents. Transfusion requirements for patients varied but were generally modest. Blood component transfusion ratios were close to that recommended. The role of base excess as a predictor of transfusion requirements in patients with similar injuries needs more study.

Preparation for the next major incident: are we ready? A 12-year update.

OBJECTIVES: A major incident is any emergency that requires special arrangements by the emergency services and generally involves a large number of people. Recent such events in England have included the Manchester Arena bombing and the Grenfell Tower disaster. Hospitals are required by law to keep a major incident plan (MIP) outlining the response to such an event. In a survey conducted in 2006 we found a substantial knowledge gap among key individuals that would be expected to respond to the enactment of an MIP. We set out to repeat this survey study and assess any improvement since our original report. METHODS: We identified NHS trusts in England that received more than 30 000 patients through the emergency department in the fourth quarter of the 2016/2017 period. We contacted the on-call anaesthetic, emergency, general surgery, and trauma and orthopaedic registrar at each location and asked each individual to answer a short verbal survey assessing their confidence in using their hospital's MIP. RESULTS: Of those eligible for the study, 62% were able to be contacted and consented to the study. In total 50% of respondents had read all or part of their hospital's MIP, 46.8% were confident that they knew where their plan was stored, and 36% knew the role they would play if a plan came into effect. These results show less confidence among middle-grade doctors compared with 2006. CONCLUSIONS: Confidence in using MIPs among specialty registrars in England is still low. In light of this, we make a number of recommendations designed to improve the education of hospital doctors in reacting to major incidents.

The crowd-out effect of a mass casualty incident: Experience from a dust explosion with multiple burn injuries.

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ±â€Š4.21 hours vs 3.77 ±â€Š2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.

A Time-Series Analysis of Firearm Purchasing After Mass Shooting Events in the United States.

Importance: Increased understanding of public response to mass shootings could guide public health planning regarding firearms. Objectives: To test the hypothesis that mass shootings are associated with gun purchasing in the United States and to determine factors associated with gun purchasing changes. Design and Setting: In a cross-sectional study, monthly data on US background checks for all firearm purchases, handgun permits, and long gun permits between November 1, 1998, and April 30, 2016, were obtained from the National Instant Criminal Background Check System. All mass shootings resulting in 5 or more individuals injured or killed during the study period were also identified. Interrupted autoregressive integrated moving average time-series modeling was used to identify events associated with changes in gun purchase volume. Then, logistic regression was used to identify event characteristics associated with changes in gun purchases. Analyses were performed between June 6, 2016, and February 5, 2019. Exposures: For the time-series analysis, each mass shooting was modeled as an exposure. In the logistic regression, examined factors were the shooter's race/ethnicity, the region in the United States in which a shooting occurred, whether a shooting was school related, fatalities, handgun use, long gun use, automatic or semiautomatic gun use, media coverage level, and state political affiliation. Main Outcomes and Measures: Identification of major mass shootings significantly associated with changes in gun purchases, and the identification of event-specific factors associated with changes in gun purchases. Results: Between November 1998 and April 2016, 124 major mass shootings and 233 996 385 total background checks occurred. A total of 26 shootings (21.0%) were associated with increases in gun purchases and 22 shootings (17.7%) were associated with decreases in gun purchasing. Shootings receiving extensive media coverage were associated with handgun purchase increases (odds ratio, 5.28; 95% CI, 1.30-21.41; P = .02). Higher-fatality shootings had an inverse association with handgun purchase decreases (odds ratio, 0.73; 95% CI, 0.53-1.00; P = .049). Conclusions and Relevance: The findings of this study suggest an association between mass shootings and changes in gun purchases, observed on a comprehensive timescale. Identification of media coverage and fatalities as significant factors underlying this association invites further study into the mechanisms driving gun purchase changes, holding implications for public health response to future gun violence.

The Las Vegas mass shooting: An analysis of blood component administration and blood bank donations.

BACKGROUND: The deadliest mass shooting in modern United States history occurred on October 1, 2017, in Las Vegas, killing 58 and overwhelming hospitals with more than 600 injured. The scope of the tragedy offers insight into medical demands, which may help guide preparedness for future mass shooting incidents. METHODS: Retrospective, deidentified, health care institution-provided data from all hospitals and blood banks providing care to Las Vegas shooting victims were gathered. Study authors independently reviewed all data and cross-referenced it for verification. Main outcomes and measures include the number of victims requiring hospital and intensive care admission, the amount and types of blood components transfused during the first 24 hours, and the amount of blood donated to local blood banks following the Las Vegas mass shooting. RESULTS: Two hundred twenty patients required hospital admission, 68 of them to critical care. Nearly 500 blood components were transfused during the first 24 hours in a red blood cell-to-plasma-to-platelet ratio of 1:0.54:0.81. Public citizens donated almost 800 units of blood immediately after the shooting; greater than 17% of this donated blood went unused. CONCLUSIONS: The amount of blood components transfused per patient admitted was similar in magnitude to other mass casualty events, and available blood supply met patient demand. The public call for blood donors was not necessary to meet immediate demand and led to resource waste. Preparation for future mass shooting incidents should include training the community in hemorrhage control, encouraging routine blood donation, and avoiding public calls for blood donation unless approved by local blood suppliers. LEVEL OF EVIDENCE: Therapeutic study, level V.

What have we learned from the time trend of mass shootings in the U.S.?

Little is known regarding the time trend of mass shootings and associated risk factors. In the current study, we intended to explore the time trend and relevant risk factors for mass shootings in the U.S. We attempted to identify factors associated with incidence rates of mass shootings at the population level. We evaluated if state-level gun ownership rate, serious mental illness rate, poverty percentage, and gun law permissiveness could predict the state-level mass shooting rate, using the Bayesian zero-inflated Poisson regression model. We also tested if the nationwide incidence rate of mass shootings increased over the past three decades using the non-homogenous Poisson regression model. We further examined if the frequency of online media coverage and online search interest levels correlated with the interval between two consecutive incidents. The results suggest an increasing trend of mass shooting incidences over time (p < 0.001). However, none of the state-level variables could predict the mass shooting rate. Interestingly, we have found inverse correlations between the interval between consecutive shootings and the frequency of on-line related reports as well as on-line search interests, respectively (p < 0.001). Therefore, our findings suggest that online media might correlate with the increasing incidence rate of mass shootings. Future research is warranted to continue monitoring if the incidence rates of mass shootings change with any population-level factors in order to inform us of possible prevention strategies.

Los primeros heridos y enfermos evacuados por vía aérea en España por la Aeronáutica Militar (1923-1927). 95º aniversario del comienzo de la Aviación Sanitaria española / The First Casualties and Patients Air Evacuated by the Spanish Military Aeronautics (1923-1927). 95th Anniversary of the Beginning of Spanish Medical Aviation

La Aviación Sanitaria comenzó en nuestro país con la adquisición por parte de la Aeronáutica Militar de los primeros aviones específicos para el transporte sanitario a finales del año 1922. El desarrollo de esta actividad aeronáutica-sanitaria se realizó en los países europeos en la década de los años 20 para satisfacer las necesidades de evacuación de los heridos graves en sus distintas guerras, sobre todo las coloniales. Durante estos años el avance de las aplicaciones de la recién nacida Aviación eran imparables en todos los campos. En España los datos de la actividad de la evacuación sanitaria de estos primeros años han sido confundidos ya que no fueron recogidos de forma sistemática. Gracias al estudio de fuentes primarias de archivos militares y de la Cruz Roja Española hemos podido analizar por primera vez los datos de la actividad de los primeros aviones que realizaron transporte de heridos en la guerra de Marruecos durante los años 1923 a 1927. Esta experiencia sanitaria nos equipararía a los países europeos más desarrollados y se correspondería con el interés científico mostrado en España por este nuevo método de transporte. En el presente año se cumple el 95º aniversario del comienzo de esta actividad fundamental en la medicina militar y de urgencia por lo que queremos rendir un homenaje con la divulgación del trabajo que realizaron durante esos años

Medical aviation started in Spain with the acquisition on the part of Military Aeronautics of the first aircraft specifically designed for medical transport by the end of 1922. The development of this aeronautical-medical activity was carried out in the European countries during the 1920s to meet the needs of evacuation of those casualties severely injured in different wars, particularly in the colonies. In those days, the improvement of the newly-born aviation was unstoppable in all fields. In Spain, the data regarding the medical evacuation of these first years are very confused for they were not gathered in a systematic way. Thanks to the study of different primary sources of the military and the Spanish Red Cross archives, a complete analysis of the data regarding the activity of the first planes which transported casulaties during the Morocco War (1923-1927) has been performed for the first time. This medical experience equates our country with the most developed European countries and it corresponds to the scientific interest proved in Spain towards this mean of transport. The 95th anniversary of the beginning of this activity, termed as fundamental in emergency and medical medicine, is celebrated this year. From these pages, the authors wish both to contribute to the dissemination of the activity carrried out by the military professionals of the time and to pay them a well- deserved homage

The Halifax Explosion a century later: Lessons for our time.

A brief historical account of the Halifax Explosion, one of North America's greatest mass urban trauma casualty events of the 20th century. This disaster, in Halifax, Nova Scotia, was the result of the cataclysmic explosion of a fully loaded World War I munitions ship on the densely waterfront of that city, resulting in nearly 2000 fatalities and 9000 injured. It remains a case study in response to disasters which overwhelm local medical capabilities.

The Great London Smog of 1952.

: The Great London Smog of December 1952 lasted five days and killed up to 12,000 people. The smog developed primarily because of extensive burning of high-sulfur coal. The health effects were both immediate and long lasting, with a recent study revealing an increased likelihood of childhood asthma development in those exposed to the Great Smog while in utero or during their first year of life. Subsequent pollution legislation-including the U.S. Clean Air Act and its amendments-have demonstrably reduced air pollution and positively impacted health outcomes. With poor air quality events like the Great Smog continuing to occur today, nurses need to be aware of the impact such environmental disasters can have on human health.

Rampage shootings: an historical, empirical, and theoretical overview.

Rampage shootings is a relatively new term to describe a phenomenon that has a long history. Rampage shootings are mass shootings (generally defined as involving four or more victims), taking place in a public location, with victims chosen randomly or for symbolic purposes. These shootings are isolated events, meaning they are not connected to another criminal act (such as robbery or terrorism). Research suggests that rampage shootings are not a new phenomenon, but have occurred throughout the US since the early 1900s. There is some evidence of an increase in recent years, but definitional differences across studies and data sources make interpreting trends somewhat tenuous. Theories regarding the perpetration of rampage shootings center on masculinity, mental illness, and contagion effects. Policies aimed at preventing rampage shootings remain somewhat controversial and not well-tested in the literature.

The 1917 Halifax Explosion: the first coordinated local civilian medical response to disaster in Canada.

SUMMARY: The 1917 Halifax Explosion was an unfortunate but predictable tragedy, given the sea traffic and munitions cargo, resulting in sudden large-scale damage and catastrophic injuries, with 1950 dead and 8000 injured. Although generous support was received from the United States, the bulk of the medical work was undertaken using local resources through an immediate, massive, centrally coordinated medical response. The incredible care provided 100 years ago by these Canadian physicians, nurses and students is often forgotten, but deserves attention. The local medical response to the 1917 disaster is an early example of coordinated mass casualty relief, the first in Canada, and remains relevant to modern disaster preparedness planning. This commentary has an appendix, available at canjsurg.ca/016317-a1.

A practical approach to Events Medicine provision.

In the past three decades, mass casualty incidents have occurred worldwide at multiple sporting events and other mass gatherings. Organisational safety and healthcare provision can consequently be scrutinised post-event. Within the UK, such incidents in the 1980s provided incentives to improve medical services and subsequent high profile UK-based international sporting events (London Olympics and Paralympics 2012, Glasgow Commonwealth Games 2014, Rugby World Cup 2015) added a further catalyst for developing services. Furthermore in the aftermath of the abandoned France versus Germany association football match at the Stade de France (Paris Terrorist Attacks, November 2015) and the 2016 UK report from HM Coroner on the Hillsborough Inquest, medical cover at sporting events is being further reviewed. Doctors providing spectator cover therefore need to have an awareness of their likely roles at sporting venues. Formal guidance exists in many countries for the provision of such cover but remains generic even though Events Medicine is increasingly recognised as a necessary service. The current evidence base is limited with best practice examples often anecdotally cited by acute care specialists (eg, emergency medicine) who provide cover. This article is therefore intended to present an overview for doctors of the knowledge and skills required to treat ill and injured spectators and enable them to adequately risk-assess venues in cooperation with other health and safety providers, including preparation for a major incident. It also gives guidance on how activity can be adequately assessed and how doctors can have management roles in Events Medicine.

Deployable, portable, and temporary hospitals; one state's experiences through the years.

This article will review the use of temporary hospitals to augment the healthcare system as one solution for dealing with a surge of patients related to war, pandemic disease outbreaks, or natural disaster. The experiences highlighted in this article are those of North Carolina (NC) over the past 150 years, with a special focus on the need following the September 11, 2001 (9/11) attacks. It will also discuss the development of a temporary hospital system from concept to deployment, highlight recent developments, emphasize the need to learn from past experiences, and offer potential solutions for assuring program sustainability. Historically, when a particular situation called for a temporary hospital, one was created, but it was usually specific for the event and then dismantled. As with the case with many historical events, the details of the 9/11 attacks will fade into memory, and there is a concern that the impetus which created the current temporary hospital program may fade, as well. By developing a broader and more comprehensive approach to disaster responses through all-hazards preparedness, it is reasonable to learn from these past experiences, improve the understanding of current threats, and develop a long-term strategy to sustain these resources for future disaster medical needs.