Terrorist attacks against healthcare facilities involving hostages.

INTRODUCTION: The incidence of terrorist attacks against healthcare facilities has been increasing over recent years. In addition to direct attacks on physical structures, many attacks have involved taking hostages. Hospital and healthcare facilities remain historically underprepared for terrorist attacks, representing vulnerable locations. Yet, studies examining the frequency and reach of hostage-taking incidents within healthcare facilities are limited. METHODS: A search of the Global Terrorism Database was performed. A total of 191,465 terrorist attacks were identified. The database search was narrowed down to healthcare-related terrorist attacks (2,322) and then manually analyzed to only include those incidents which involved hospitals and hostage-taking (64). RESULTS: Sixty-four attacks against hospitals involving hostage-taking were identified. A total of 91 victims were injured in these attacks, and 47 were killed. The attacks affected a total of 23 countries worldwide, conducted largely by unidentified terrorist organizations, with approximately half involving firearms. DISCUSSION: This study shows that terrorist attacks against healthcare facilities that involve -hostage-taking have increased in frequency over the past 10 years and have global reach. Systems may still be underprepared for this potentially increasing phenomenon and require preparedness plans with education and simulated practice in place. Healthcare facilities should consider mitigation strategies such as preparedness drills and additional education.

Terrorist attacks against women's healthcare facilities 1970-2018.

INTRODUCTION: Targeted acts of violence against women's healthcare facilities and healthcare providers are a continued threat to the safety and well-being of those seeking reproductive care as well as those who provide it around the world. STUDY OBJECTIVES: This study aims to review and analyze terrorist attacks against facilities and providers who offer women's healthcare services globally. METHODS: A thorough analysis of data coming from the Global Terrorism Database (GTD) was performed. This database is run by the National Consortium for the Study of Terrorism and Responses to Terrorism. RESULTS: Two hundred and seventy-one incidents registered in the GTD between 1970 and 2018 were found to be terrorist attacks on women's healthcare facilities, the majority of which occurred in the United States. The method of attack or weapons used varied greatly. While the majority of these attacks targeted facilities, a number of attacks focused on individuals, namely, healthcare providers. CONCLUSION: Facilities and providers associated with women's healthcare services, particularly reproductive health, remain at risk of terror attack. Although carried out by a variety of groups and with diverse methods, these attacks appear most prevalent, or most reported, in Western society and threaten essential reproductive healthcare.

Terrorist Attacks Against Firefighters, 1970-2019.

Firefighters are a critical component of the emergency response system and therefore a potential target for organizations seeking to disrupt this system. Terrorist organizations may deliberately attack firefighters to both increase the devastation of an attack and impair the affected community's ability to respond to an attack. We performed a focused search of the Global Terrorism Database to identify terrorist attacks against firefighters worldwide. The database includes incidents from 1970 through 2019, with a total of 201,183 entries. These entries were searched for incidents involving firefighters or fire trucks. We analyzed trends in the number of incidents occurring per year, regions of the world impacted, methods employed, and number of casualties inflicted. A total of 42 attacks involving firefighters were identified in the Global Terrorism Database resulting in 26 deaths and 95 wounded. Of the 42 attacks, 12 (28.6%) were secondary attacks, where firefighters responding to an initial attack were themselves targeted. The most common method for both primary and secondary attacks was the use of a bomb or explosive. Although attacks against firefighters are uncommon, they highlight both the strategic value and vulnerability of firefighters to terrorist attacks. Increased efforts must be made to protect firefighters from future terrorist attacks.

Terrorist Attacks Against Performing Arts Venues: Global Trends and Characteristics Spanning 50 Years.

INTRODUCTION: In fostering community and culture through entertainment in shared spaces, performing arts venues have also become targets of terrorism. A greater understanding of these attacks is needed to assess the risk posed to different types of venues, to inform medical disaster preparedness, to anticipate injury patterns, and to reduce preventable deaths. METHODS: A search of the Global Terrorism Database (GTD) was conducted from the year 1970 through 2019. Using pre-coded variables for target/victim type and target subtype, attacks involving "business" and "entertainment/cultural/stadium/casino" were identified. Attacks targeting performing arts venues were selected using the search terms "theater," "theatre," "auditorium," "center," "hall," "house," "concert," "music," "opera," "cinema," and "movie." Manual review by two authors was performed to confirm appropriateness for inclusion of entries involving venues where the primary focus of the audience was to view a performance. Descriptive statistics were performed using R (version 3.6.1). RESULTS: A total of 312 terrorist attacks targeting performing arts venues were identified from January 1, 1970 through December 31, 2019. Two-hundred nine (67.0%) attacks involved cinemas or movie theaters, 80 (25.6%) involved unspecified theaters, and 23 (7.4%) specifically targeted live music performance venues. Two-hundred thirty-four (75.0%) attacks involved a bombing or explosion, 50 (16.0%) damaged a facility or infrastructure, and 17 (5.4%) included armed assault. Perpetrators used explosives in 234 (75.0%) attacks, incendiary weapons in 50 (16.0%) attacks, and firearms in 19 (6.1%) attacks. In total, attacks claimed the lives of 1,307 and wounded 4,201 persons. Though fewer in number, attacks against music venues were responsible for 29.4% of fatalities and 35.0% of those wounded, and more frequently involved the use of firearms. Among 95 attacks falling within the highest quartile for victims killed or wounded (>two killed and/or >ten wounded), 83 (87.4%) involved explosives, seven (7.4%) involved firearms, and three (3.2%) involved incendiary methods. CONCLUSION: While uncommon, terrorist attacks against performing arts venues carry the risk for mass casualties, particularly when explosives and firearms are used.

The Rising Threat of Terrorist Attacks Against Hospitals.

INTRODUCTION: Hospitals are vulnerable to terrorist attacks, as they must remain easily accessible to the general public. Hospitals are also occupied with both staff and patients 24 hours a day, 365 days a year, meaning that any attack is almost guaranteed to inflict a multitude of casualties. In addition to the immediate effects of attacking a hospital, there are also uniquely devastating second- and third-order effects when hospitals are attacked. METHODS: A focused search of the Global Terrorism Database (GTD) was performed to identify terrorist attacks against hospitals throughout the world. Data between the years 1970-2018 were selected, which included 191,465 entries in total. These entries were then searched for incidents containing the term "hospital" and the results were manually searched to identify trends in the number of incidents occurring per year, as well as the armament that was employed, and the regions of the world where the attacks occurred. RESULTS: A total of 430 terrorist attacks on hospitals were identified in the GTD, resulting in 1,291 deaths and an additional 1,921 wounded. The frequency of terrorist attacks against hospitals has been steadily increasing over the last two decades and is disproportionate to the overall increase in terrorist attacks against all target types. Attacks have been carried out against hospitals in 61 different countries. The most common method used in these attacks was "bombing/explosion," which accounted for 299 attacks. Of the known terrorist groups identified in the GTD, "Houthi extremists (Anshar Allah)" and "Islamic State of Iraq and the Levant (ISIL)" carried out the greatest number of attacks on hospitals. CONCLUSION: There has been a disproportionate rise in the frequency of terrorist attacks on hospitals when compared to other target types, highlighting the vulnerability of these key structures. Unsurprisingly, these attacks have inflicted large casualty counts in addition to disrupting community health care and disaster response. Attacks against hospitals have been reported on every inhabited continent except Australia, making their protection a matter of international security. The rate of terrorist attacks on hospitals has increased dramatically over the last two decades, creating an urgent need to develop improved defense strategies that will better ensure their protection.

Emergency Department Diagnosis of Postprocedural Hemorrhagic Cholecystitis Utilizing Point-of-Care Ultrasound.

BACKGROUND: Hemorrhagic cholecystitis is a rare cause of abdominal pain. Most often described in the setting of blunt abdominal trauma, anticoagulation use, coagulopathy (such as cirrhosis or renal failure), and malignancy (biliary angiosarcoma), this rare condition can be difficult to identify unless high on the differential. With point-of-care ultrasound becoming more commonplace in the emergency department (ED), this tool can be successfully used to make a timely diagnosis in the correct clinical context. CASE REPORT: A 64-year-old man with a past medical history of paroxysmal atrial fibrillation status post ablation on rivaroxaban, myelodysplastic syndrome, nonalcoholic steatohepatitis, gastroesophageal reflux disease, clonal cytopenias of undetermined significance, hypertension, and chronic pain presented to the ED with complaints of right upper quadrant pain in the setting of a recent transjugular liver biopsy. Using point-of-care ultrasound, the patient was diagnosed with hemorrhagic cholecystitis. This is an incredibly rare entity, with 87 documented cases in the literature, only two of which are in the setting of transjugular liver biopsy. The patient was ultimately managed conservatively until he had worsening symptoms, and a laparoscopic cholecystectomy was performed. The patient tolerated the procedure well and recovered. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hemorrhagic cholecystitis is a rare pathology that can be easily recognized during point-of-care ultrasound examination. This allows for rapid diagnosis and surgical consultation to provide the patient with timely definitive management.

Terrorist Attacks Against Vaccinators: A Review.

Vaccinators fulfill an important role in a nation's public health by reducing the burden of disease on the population. Understanding patterns of attack employed against vaccinators is important to determine how to protect them. We conducted a search of the Global Terrorism Database for terrorist attacks against vaccinators that occurred between the years 1970 and 2018. Using the search terms "hospital," "healthcare," "clinic," "doctor," "nurses," "vaccinators," and "vaccinations," 2,322 healthcare-related entries were identified. We then manually searched the dataset for incidents related to attacks on vaccinators, which resulted in the identification of 133 attacks against vaccinators. The majority (128 out of 133) of attacks occurred during or after 2010. Every attack except one has occurred in the Middle East, South Asia, or sub-Saharan Africa. Pakistan has seen the most attacks against vaccinators, with 112 incidents recorded. Vaccinators continue to be vulnerable to terrorist attacks. Protection of healthcare personnel during mass vaccination efforts is critical so that they can continue their lifesaving mission.

19-year-old Woman with Intermittent Weakness.

INTRODUCTION: Systemic weakness is a common chief complaint of patients presenting to the emergency department (ED). A well thought out approach to the assessment and workup of these patients is key to diagnostic accuracy and definitive therapy. CASE PRESENTATION: In this case, a 19-year-old female presented to the ED with generalized weakness and near syncope. She had global weakness in her extremities and multiple electrolyte abnormalities. DISCUSSION: This case takes the reader through the differential diagnosis and evaluation of a patient with weakness and profound electrolyte derangements. It includes a discussion of the diagnostic studies and calculations that ultimately led to the patient's diagnosis.

Terrorist Attacks Against Healthcare Facilities: A Review.

Healthcare facilities play an essential role in response to terrorist attacks, but they also can be "soft targets" due to their accessibility and limited security. In this review, the authors used the Global Terrorism Database to conduct a search on terrorist attacks directed against hospitals and healthcare facilities between 1970 and 2018. Search terms included "healthcare," "doctor," "nurses," "vaccinators," "clinic," and "hospital," which resulted in 2,322 healthcare-related entries. The dataset was then manually searched for attacks on healthcare facilities, resulting in a total of 901 attacks in 74 different countries. The prevalence of healthcare facility attacks has increased, with 57% (515) occurring after 2001. The most common method of attack was bombing, followed by direct attacks on healthcare infrastructure and armed assaults. Healthcare facilities remain vulnerable to violence, and lessons learned in the aftermath of these incidents can be used to raise awareness about important safety-related concerns within the national response framework. Healthcare and security experts must be aware of the vulnerability of this crucial infrastructure and take active steps to prevent attacks.

Difficulty Ventilating: A Case Report on Ventilation Considerations of an Intubated Asthmatic Undergoing Air Medical Critical Care Transport.

The air medical transport of intubated patients is a high-risk mission that requires preplanning before helicopter launch. This case describes a scenario in which the helicopter emergency medical services (HEMS) team was unable to ventilate a patient because of the mechanical limitations of the transport ventilator. The HEMS mission was ultimately aborted, and the patient had to be transported by a ground crew equipped with a hospital-based ventilator. In addition to the optimal medical management of the patient in status asthmaticus, critical care transport crews must be familiar with the treatment of patients exhibiting extremely high peak airway pressures. Specifically, ventilator manipulations as well as the technical specifications of the transport ventilator may preclude the patient from being transported by the HEMS team. It is imperative that the patient's current ventilator setting be evaluated before the launch of the aircraft to prevent any possible delays in patient care.

Terrorists Use of Ambulances for Terror Attacks: A Review.

INTRODUCTION: Using an ambulance as an attack modality offers many advantages to a terrorist organization. Ambulances can carry more explosives than most vehicles and can often bypass security. Yet, studies examining how terrorist organizations have incorporated ambulances into their attacks are lacking. STUDY OBJECTIVE: This article seeks to identify and analyze known instances in which an ambulance has been used in a terrorist attack. METHODS: The Global Terrorism Database (GTD) was searched for terrorist events that involved the use of an ambulance from the years 1970-2018. Variables of event time, location, and loss of life were analyzed. RESULTS: Twenty instances where an ambulance had been used in a terrorist attack were identified from the GTD. Fifteen of the attacks occurred in the Middle East, while the remaining five occurred in Southeast Asia. All attacks except one had occurred after 2001, and 13 had occurred within the past decade. Most attacks (12/20) resulted in up to three people killed, while six attacks had 10-20 casualties. The deadliest attack occurred in Kabul, Afghanistan in 2018 and caused over 100 casualties. One event did not have casualty information in the GTD. In all cases, ambulances were used as vehicle-borne improvised explosive devices (VBIED) by terrorist organizations. CONCLUSION: This study shows that terrorists are increasingly acquiring and utilizing ambulances in their attacks, often with deadly consequences. Security and public health experts must be aware of this hazard and work to deny terrorists access to these vehicles.